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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 - 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
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 - 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
×
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
×
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
×
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 Extubation
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 #9 Preventing Sepsis - Update - 05.04.19
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Commitment Update
×
UCI Health
APSS #9 Preventing Sepsis – Update – 05.04.19
Contact Info
Name: WILLIAM WILSON
Phone: 714-456-6844
Email: wcw@uci.edu
Position: Chief Medical Officer
Organization Name: UCI Health
Commitment Details Commitment Start Date: 01/01/2018 How many hospitals are represented in this commitment?
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 algorithm.
Sepsis is monitored by hospital leadership through the organizational crosswalk for progress accountability.
Commitment Update:
To increase compliance with current evidence-based guidelines for sepsis an evaluation of our nurse-driven sepsis screening best practice alert (BPA) was completed. It was determined that the electronic screening tool and alert system in the EMR were not effective, it was not triggering accurately and was also did not align with the current workflow. The screening process required an update. All patients will be screened/assessed/reassessed for sepsis, severe sepsis, &/or septic shock in the ED and upon admission to all inpatient floors and/or units. The sepsis assessment tool will be completed in the electronic medical record (EMR) by the Registered Nurse (RN). To evaluate and/or update the patient’s status, to reflect changes, and/or to address additional treatment needs, ongoing reassessment will occur throughout hospitalization. The next step will be to implement a standardized, physician approved, nursing protocol. The physician approved protocol will be implemented hospital wide. The protocol will allow the RN to assess and/or screen patients for Sepsis, Severe Sepsis or Septic Shock, and protocol-based nursing interventions will allow the RN to initiate early treatment. Guidance will be provided to the nursing staff on information that should be communicated to the physician when patients screen positive for Sepsis.
To address progress and accountability sepsis is monitored by hospital leadership through our sepsis dashboard, the dashboard includes monitoring SEP-1 bundle adherence, sepsis mortality, sepsis readmissions, length of stay, and post-operative sepsis. There is currently an ongoing evaluation for the implementation of a reflux order for “Repeat Sepsis Lactate” this would include a notification by the lab whenever a “Sepsis Lactate” is above 2.
A suspected sepsis order set is now embedded into our EMR.
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
Reinforcing the importance of adhering to the Surviving Sepsis Campaign guidelines the revision and implementation of a standardized suspected sepsis order set, the evaluation and monitoring of our electronic best practice alert for early identification of sepsis. Implementation of a nurse driven protocol is underway.
Impact Details
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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
×
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
×
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
×
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
×
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
×
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
×
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 Tube (NGT) 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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UCI Health |
CA |
US |
Challenge 16: Optimizing Person and Family Engagement
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Commitment
×
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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Parrish Medical Center |
Fl |
US |
Sustaining a Culture of Safety
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Commitment
×
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 - 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 - 12.06.18
View Update
Commitment Update
×
Parrish Medical Center
Sustaining a Culture of Safety – Update – 12.06.18
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:
Parrish Healthcare has completed board governance culture of safety survey. Action plan has been developed and initiated. Two tactics that have been deployed have been a signature to our commitment to safety by all care partners including governance and organizational wide education and commitment to the WHO Hand Hygiene program.
Your commitment aligns with APSS
Challenge 1 - Culture of Safety Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
Use of defined performance improvement strategies in concert with evidence based practices create optimal results.
Impact Details
| Initial Commitment |
Commitment Update |
Project Next Year |
Lives Lost
00 |
Lives Lost
0 |
Lives Lost:
0 |
Lives Spared Harm Target
00 |
Actual Lives Spared Harm in last 12 months
38 |
Lives Spared Harm Target for following calendar year
38 |
Lives Saved Target
00 |
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
1 |
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New Lives Lost (lives lost – actual lives saved)
0 |
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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 - 12.06.18
View Update
Commitment Update
×
Parrish Medical Center
Transitions in Caring – Update – 12.06.18
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:
Establish an HOC core team; review current and PSMF HOC checklists; conduct PI analysis using LSS/DMAIC process; provide education for all involved in HOC; measure and analyze the effectiveness of current HOC processes; evaluate technology plan for support utilization. Utilize the recently accepted (1/18/18) "ED to Med/Surg Safe Hand-off Checklist" during this subset group currently in the measure phase. Nursing continue to use SBAR form when receiving handover report; document within the EMR "Transfer: Handoff Report" and participate in the Safe Discharge meeting using the Safe Discharge sheet (Code Salmon sheet).
Commitment Update:
Will facilitate change using the change management model by the Joint Commission of: plan the project; Inspire people; Launch the initiative; and Support the change. The HOC core team will be multidisciplinary and utilize the Lean Six Sigma DMAIC methodology for opportunities for defining HOC; strengthening the sender/receiver message; and implementing the checklist solution.
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
See original 2018 commitment
Impact Details
| Initial Commitment |
Commitment Update |
Project Next Year |
Lives Lost
|
Lives Lost
0 |
Lives Lost:
0 |
Lives Spared Harm Target
6000 |
Actual Lives Spared Harm in last 12 months
48 |
Lives Spared Harm Target for following calendar year
48 |
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
1 |
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New Lives Lost (lives lost – actual lives saved)
0 |
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Parrish Medical Center |
Fl |
US |
Nasogastric Feeding and Drainage Tube Placement and Verification
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Commitment
×
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 Tube (NGT) 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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Nasogastric Feeding and Drainage Tube Placement and Verification - Update - 07.02.19
View Update
Commitment Update
×
Parrish Medical Center
Nasogastric Feeding and Drainage Tube Placement and Verification – Update – 07.02.19
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
Commitment Details How many hospitals are represented in this commitment?
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 Update:
Patients that have an NG/OG tube placed at Parrish Medical Center. 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. Started in January 2019.
Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
Vendors who manufacture NG/OG tubes need to update their IFU's to have pH testing included as the first option.
Our main challenge is the order to collection time in minutes which was for January 2019 at 39.59, February 11.49, March 95.47, April 78.07 and May 66.22 minutes.
1.Specimen sometimes are being sent to the laboratory without orders which is causing delays in processing and testing of specimen.
2. All Gastric pH above 5 to have x-ray done to ensure placement of NG/OG tube is correct, right now not all Gastric pH above 5 have X-Ray order.
3. Gastric pH not currently being done on infants, needs assessment is currently being processed by Women’s Center Manager.
Your commitment aligns with APSS
Challenge 15 - Nasogastric Tube (NGT) Placement and Verification Impact DetailsBy implementing the APSS, what cost benefits have you attained in the following areas?:
Reduction in complication rates:
This is the estimated lives saved so far this year:
• 261 patients had the gastric PH performed. The benchmark average serious harm was reported 2.25% of the tubes placed caused serious harm. Estimated 6 lives were saved this year so far.
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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 - 12.06.18
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Commitment Update
×
Parrish Medical Center
FAILURE TO RESCUE: MONITORING FOR OPIOID INDUCED RESPIRATORY DEPRESSION – Update – 12.06.18
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:
Repeat FMEA to assess for additional opportunities and/or Perform performance improvement plan using the DMAIC process.
Commitment Update:
Continue to monitor and evolve an effective program to reduce opioid-induced respiratory depression leading to zero harm to our patients
Continue to have multidisciplinary team to evaluate and implement EBP, educate family, and educate care partners.
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
See original 2018 commitment
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
1 |
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
1 |
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New Lives Lost (lives lost – actual lives saved)
0 |
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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
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Airway Safety - Update - 12.06.18
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Commitment Update
×
Parrish Medical Center
Airway Safety – Update – 12.06.18
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:
Continue to modify and develop Failed Airway protocol, standardized airway cart/box and equipment, hardwire and maintain EBP critical practices, and continue to educate team with competencies for protocol, equipment and critical practices.
Commitment Update:
Developed a mandatory query in EMR to track unplanned extubation for patients undergoing mechanical ventilation via endotracheal tube to help maintain zero harm.
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
See original 2018 commitment
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
1 |
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
1 |
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|
New Lives Lost (lives lost – actual lives saved)
0 |
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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 - 12.06.18
View Update
Commitment Update
×
Parrish Medical Center
Sepsis – Update – 12.06.18
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:
PMC's Sepsis Committee is a multi-disciplinary institutional group currently in place primarily responsible for sepsis protocols and processes, with a focus on reducing preventable deaths and ensuring an institutional culture of safety pertaining to sepsis. Responsibilities include reviewing, revising, or creating protocols following evidence based practice, technology, and performance data, and ensuring training and education to specific provider types and clinical units.
Commitment Update:
According to the Surviving Sepsis Campaign International Guidelines (2012), patients diagnosed with sepsis have a mortality rate of 16 to 49 percent. Despite advances in health care, sepsis continues to plague the industry by being a leading cause of death, readmissions, and health care expenditures. They also identified sepsis as a key opportunity for improving patient safety, reducing preventable deaths, and decreasing healthcare expenditure. Our commitment is through the use of technology, evidence based practice and collaboration, to create a coordinated effort to improve clinical outcomes. PMC's Code Sepsis Committee is a multi-disciplinary institutional group currently in place primarily responsible for sepsis programs, with a focus on reducing preventable deaths and ensuring an institutional culture of safety pertaining to optimal resuscitation. Responsibilities include reviewing, revising, or creating protocols following evidence based practice, technology, and performance data, and ensuring training and education to specific provider types and clinical units. PMC will use its existing Sepsis Committee as the steering committee for assessing opportunities, identifying and implementing solutions, and gathering/reporting of data pertaining to this APSS. Code Sepsis cases and any calls will be monitored weekly and any variance will be entered into RL Solutions for resolution and tracking purposes.
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
See original 2018 commitment.
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
1 |
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)
0 |
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Parrish Medical Center |
Fl |
US |
SSI - Surgical Site Infection for COLO and HYST procedures
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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 - 12.06.18
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Commitment Update
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Parrish Medical Center
SSI – Surgical Site Infection for COLO and HYST procedures – Update – 12.06.18
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:
Maintain EBP bundles, perform active surveillance to monitor for: ED visit, readmission 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, and perform assessments of OR pressures and OR traffic. Several formal Performance Improvement plans have been implemented throughout PMC focused on following EBP to achieve our goal.
Commitment Update:
A small PI focused multidisciplinary team was developed to evaluate and implement EBP to achieve zero occurrence in this population. We also leverage the hospital wide Infection Control Committee for further review, reporting, and support.
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
See original 2018 commitment
Impact Details
| Initial Commitment |
Commitment Update |
Project Next Year |
Lives Lost
0 |
Lives Lost
0 |
Lives Lost:
-3 |
Lives Spared Harm Target
0 |
Actual Lives Spared Harm in last 12 months
0 |
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)
3 |
Projected Target of Lives Saved for following calendar to try to finish commitment
3 |
|
|
New Lives Lost (lives lost – actual lives saved)
-3 |
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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 (pedVAP/PVAP)
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 - 12.06.18
View Update
Commitment Update
×
Parrish Medical Center
VAE/IVAC – Ventilator Associated Event w/infection – Update – 12.06.18
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 PEEP/FiO2 for events, maintain EBP bundles, perform daily needs assessment for devices
Commitment Update:
Multidisciplinary team to continue to evaluate and implement EBP to maintain zero occurrence.
Your commitment aligns with APSS
Challenge 2D - Ventilator-associated pneumonia (pedVAP/PVAP) Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
See original 2018 commitment.
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
1 |
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
1 |
|
|
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
View Commitment
Commitment
×
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.
|
Distribution of “Baby Boxes” to decrease the incidence of co-bedding and SIDs deaths - Update - 12.06.18
View Update
Commitment Update
×
Parrish Medical Center
Distribution of “Baby Boxes” to decrease the incidence of co-bedding and SIDs deaths – Update – 12.06.18
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. 800 new Baby Boxes have been donated by the Jess Parrish Foundation for distribution in 2017 & 2018
2. Baby Boxes continue to be distributed to every family since it’s initiation on May 23, 2016.
3. We will continue to investigate additional funding sources for future purchases of the Baby Boxes and supplies.
4. County wide stats continue to be monitored for effect on SIDS deaths.
5. Distribution of "Baby Boxes" to decrease the incidence of co-bedding and SIDs deaths poster presentation at the annual FPQC conference in April 2018
6. Explore funding options – Approval to receive co-grant from The Parrish Foundation and the Parrish Physicians Group for 2019
Commitment Update:
All families of Newborns delivered at Parrish Medical Center will be given a no-cost, Baby Box with education on its use, and reinforcement of the evidence which recommends babies sleep on a firm surface, without pillows, blankets and toys or in an adult's bed - that can smother them.
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
See original 2018 commitment
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
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)
-4 |
|
|
|
Parrish Medical Center |
Fl |
US |
Critical Congenital Heart Disease Screening in Newborns
View Commitment
Commitment
×
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.
|
Critical Congenital Heart Disease Screening in Newborns - Update - 12.06.18
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Commitment Update
×
Parrish Medical Center
Critical Congenital Heart Disease Screening in Newborns – Update – 12.06.18
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 algorithm.
Results are entered into the EMR and reported to the responsible physician for follow-up.
Commitment Update:
Pulse oximetry screenings will be performed and evaluated on all newborns according to the American of Pediatrics standards.
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
See original 2018 commitment.
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
1 |
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
1 |
|
|
New Lives Lost (lives lost – actual lives saved)
0 |
|
|
|
Parrish Medical Center |
Fl |
US |
Pediatric Adverse Drug Events
View Commitment
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
|
Pediatric Adverse Drug Events - Update - 12.06.18
View Update
Commitment Update
×
Parrish Medical Center
Pediatric Adverse Drug Events – Update – 12.06.18
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
Commitment Details Commitment Start Date: 01/01/2018 How many hospitals are represented in this commitment?
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 Update:
Multidisciplinary team to evaluate safe practices based on EBP that are not currently in place to further strengthen our processes in achieving zero harm to our pediatric population.
Your commitment aligns with APSS
Challenge 3D - Pediatric Adverse Drug Events Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
See original 2018 commitment
Impact Details
| Initial Commitment |
Commitment Update |
Project Next Year |
Lives Lost
1 |
Lives Lost
1 |
Lives Lost:
1 |
Lives Spared Harm Target
1 |
Actual Lives Spared Harm in last 12 months
0 |
Lives Spared Harm Target for following calendar year
1 |
Lives Saved Target
1 |
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
1 |
|
|
New Lives Lost (lives lost – actual lives saved)
1 |
|
|
|
Parrish Medical Center |
Fl |
US |
Hand Hygiene
View Commitment
Commitment
×
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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Hand Hygiene - Update - 12.06.18
View Update
Commitment Update
×
Parrish Medical Center
Hand Hygiene – Update – 12.06.18
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
Commitment Details Commitment Start Date: 01/01/2018 How many hospitals are represented in this commitment?
Action Plan:
Perform assessment of location of alcohol based hand rub, develop and implement hand wash signs for patients with known or suspected C. difficile diarrhea, and develop continuing education of hand hygiene through our trained observers.
Commitment Update:
Develop multidisciplinary team to provide continuing education on EBP to maintain 100% compliance.
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
See original 2018 commitment.
Impact Details
| Initial Commitment |
Commitment Update |
Project Next Year |
Lives Lost
1 |
Lives Lost
1 |
Lives Lost:
1 |
Lives Spared Harm Target
1 |
Actual Lives Spared Harm in last 12 months
7 |
Lives Spared Harm Target for following calendar year
7 |
Lives Saved Target
1 |
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
1 |
|
|
New Lives Lost (lives lost – actual lives saved)
1 |
|
|
|
Parrish Medical Center |
Fl |
US |
Maintain Zero Hospital-Acquired Stage III and IV Pressure Ulcers
View Commitment
Commitment
×
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.
|
Maintain Zero Hospital-Acquired Stage III and IV Pressure Ulcers - Update - 12.06.18
View Update
Commitment Update
×
Parrish Medical Center
Maintain Zero Hospital-Acquired Stage III and IV Pressure Ulcers – Update – 12.06.18
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 Leadership of PMC is committed to supporting the Pressure Ulcer Prevention effort, our care partners and Medical Staff as we strive to maintain our culture of patient safety. PMC maintains a supply of pressure reduction mattress replacements on site. This 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 data 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. Evaluation of new hospital beds and support surfaces is complete. Additions to the PUP team are planned with the enhanced education to identify patients at risk and mitigate patient injury from pressure related occurrences. Improvements to the EMR are monitored to enhance nurse compliance and ease of charting
Commitment Update:
Maintenance will be dependent on continued attention and a diligent focus from all levels to rapidly identify patients admitted with a PU. Specially educated nurses provide a resource on the hospital floors to consult with regarding HAPU prevention and treatment. They participate in data collection for NDNQI monitoring for compliance with hospital policy and procedures. The solutions Algorithms for Skin and Wound Care is a guideline detailing plan of care and treatment options for wounds and is provided to each unit for easy reference and access to the staff. New products such as skin barriers, support surfaces and pressure relieving devices are undergoing review for efficacy. In-services and reviews on product used are provided to staff to maintain competencies as needed. These efforts are coordinated and monitored by the CWON Coordinator
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
See original 2018 commitment.
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
1 |
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
1 |
|
|
New Lives Lost (lives lost – actual lives saved)
0 |
|
|
|
Parrish Medical Center |
Fl |
US |
Zero Falls with injury for our patients
View Commitment
Commitment
×
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 - 12.06.18
View Update
Commitment Update
×
Parrish Medical Center
Zero Falls with injury for our patients – Update – 12.06.18
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 process for patient fall risk was revised and interventions reviewed. The development of an all or nothing approach for patients at risk was established and a fall bundle was created. Each patient at risk would be visually identified using yellow non skid socks, door magnets, and wristbands in addition to bed alarms and chair alarms when out of bed. Additional strategies' included frequent observation and hourly rounding. A new computer based learning module was created for both clinical and non-clinical staff with an accountability statement. This created a base line for expectations from both the clinical and non-clinical care partner. Review of clinical equipment for function and efficacy as well as development of a new process for patient safety when out of bed for all at risk patients. Ancillary staff such as EVS and dietary were also enlisted for alarms awareness and response to alarms. 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 the Zero Falls with injury safety initiative.
Commitment Update:
The patient safety improvement strategic plan for Zero Falls with injury was developed using the DMAIC process of lean Six Sigma. Data collection and voice of the customer identified 3 crucial elements: 1) Failure to follow established processes for patients at risk for falls. 2)Gaps in education regarding fall prevention for patients, family and staff. 3) Gaps in communication with patient, family, staff and ancillary support departments. A multidisciplinary Process Improvement Team was organized to identify these specific problems and utilize the expertise of other disciplines to cohesively develop a plan, monitor outcomes and modify the process to make patient safety a priority
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
See original 2018 commitment.
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
1 |
|
|
New Lives Lost (lives lost – actual lives saved)
0 |
|
|
|
Parrish Medical Center |
Fl |
US |
Medication Errors
View Commitment
Commitment
×
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
|
Medication Errors - Update - 12.06.18
View Update
Commitment Update
×
Parrish Medical Center
Medication Errors – Update – 12.06.18
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
Commitment Details Commitment Start Date: 01/01/2018 How many hospitals are represented in this commitment?
Action Plan:
Review results
prioritize actionable recommendations
Implement recommendations
Monitor for effectiveness
Commitment Update:
Implement recommendations from the ISMP medication safety self assessment survey
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
See original commitment
Impact Details
| Initial Commitment |
Commitment Update |
Project Next Year |
Lives Lost
1 |
Lives Lost
1 |
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
1 |
Lives Saved Target
1 |
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
1 |
|
|
New Lives Lost (lives lost – actual lives saved)
1 |
|
|
|
Parrish Medical Center |
Fl |
US |
CAUTI-Indwelling Catheter Associated Urinary Tract Infection
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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 - 12.06.18
View Update
Commitment Update
×
Parrish Medical Center
CAUTI-Indwelling Catheter Associated Urinary Tract Infection – Update – 12.06.18
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, implement nurse driven protocol, assessment/education on alternatives to indwelling urinary catheters.
Commitment Update:
Implement policy and procedure following EBP for indwelling foley catheter insertion and maintenance to reduce foley utilization and to maintain zero occurrence.
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
Please see original 2018 commitment.
Impact Details
| Initial Commitment |
Commitment Update |
Project Next Year |
Lives Lost
0 |
Lives Lost
1 |
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
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 |
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.
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CLABSI-Central Line Associated Bloodstream Infection - Update - 12.06.18
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Commitment Update
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Parrish Medical Center
CLABSI-Central Line Associated Bloodstream Infection – Update – 12.06.18
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, perfom daily needs assessment for devices, eliminate unnecessary blood draws from lines, perform RCA's on all CLABSI's, document tubing changes
Commitment Update:
Developed multidisciplinary team to evaluate and implement EBP to maintain zero occurrence.
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
See original 2018 commitment.
Impact Details
| Initial Commitment |
Commitment Update |
Project Next Year |
Lives Lost
0 |
Lives Lost
0 |
Lives Lost:
-3 |
Lives Spared Harm Target
0 |
Actual Lives Spared Harm in last 12 months
3 |
Lives Spared Harm Target for following calendar year
3 |
Lives Saved Target
0 |
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
3 |
|
|
New Lives Lost (lives lost – actual lives saved)
-3 |
|
|
|
Parrish Medical Center |
Fl |
US |
LAB ID event for hospital onset MRSA bloodstream infection and Clostridium difficile infection
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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.
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LAB ID event for hospital onset MRSA bloodstream infection and Clostridium difficile infection - Update - 12.06.18
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Commitment Update
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Parrish Medical Center
LAB ID event for hospital onset MRSA bloodstream infection and Clostridium difficile infection – Update – 12.06.18
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, educate family members on infections, continue to educate on appropriate testing (diagnostic stewardship), evaluate decolonization protocol for MRSA.
Commitment Update:
Develop multidisciplinary team to evaluate and implement EBP to achieve zero occurrence
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
See original 2018 commitment
Impact Details
| Initial Commitment |
Commitment Update |
Project Next Year |
Lives Lost
0 |
Lives Lost
0 |
Lives Lost:
-19 |
Lives Spared Harm Target
0 |
Actual Lives Spared Harm in last 12 months
0 |
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)
19 |
Projected Target of Lives Saved for following calendar to try to finish commitment
19 |
|
|
New Lives Lost (lives lost – actual lives saved)
-19 |
|
|
|
Parrish Medical Center |
Fl |
US |
Antimicrobial Stewardship
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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
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.
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Antimicrobial Stewardship - Update - 12.06.18
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Commitment Update
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Parrish Medical Center
Antimicrobial Stewardship – Update – 12.06.18
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 Preauthorization Requirements
Educate and promote ASP strategies and prescribing criteria.
Antimicrobial Order Forms or Order Sets
Dose Optimization
IV to PO Conversion
48 hour antibiotic timeout
Commitment Update:
Coordinated interventions designed to improve and measure the appropriate use of antimicrobial agents by promoting the selection of the optimal antimicrobial regimen including dosing, duration of therapy, and route of administration.
Your commitment aligns with APSS
Challenge 3B - Antimicrobial Stewardship Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
See original 2018 commitment
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)
0 |
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 |
Optimizing Obstetrical Safety Specifically In The Area Of Hypertensive Disorders of Pregnancy
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Commitment
×
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 11B - Severe Hypertension in Pregnancy and Postpartum
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 - 12.06.18
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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 – 12.06.18
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:
• Completed review of literature which included AWHONN and AGOG standards, FPQC, and CMQCC - completed 3/15/2018
• Continuing to review and update current policies and procedures for management of Preeclampsia and Magnesium Sulfate administration, as well as pharmaceutical management of hypertension in pregnancy - in progress
• Continue data collection and chart reviews for all Hypertensive disorders in pregnancy - ongoing
• Collaborate with Physicians to provide a standardized treatment plan for patients presenting with risk factors or indications suggesting hypertensive disorders in pregnancy - Met with Dr. Weinman 4/5/18
• Educate staff to recognize risk factors and indications suggesting hypertensive disorders in pregnancy - April 2018 unit meeting
Commitment Update:
We have a multidisciplinary team of nurses, Obstetricians, and Pharmacists that will be reviewing the most current guidelines and current stands of care for managing patients with Hypertensive disorders in pregnancy. A review of all Labor & Delivery policies and procedures including risk assessment, protocols, medication management and documentation will be completed this quarter
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
See original 2018 commitment.
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
1 |
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
1 |
|
|
New Lives Lost (lives lost – actual lives saved)
0 |
|
|
|
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 - 12.06.18
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Commitment Update
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Parrish Medical Center
Neonatal Oxygen Targeting – Update – 12.06.18
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:
Oxygen administration will be determined by the targeting parameters using the SPO2
Commitment Update:
1. New education with the updated NRP guidelines has already started and will continue being reinforced with NRP classes.
2. Procedures and protocols for optimal oxygenation including targets and alarm settings for both term and preterm newborns were updated.
3. Budget for new and improved pulse oximeters and heated & humidified oxygen for every Birthing room as needed, we currently have portable oxygen set ups with heated and humidified oxygen available on the unit.
4. Continue data collection and monitoring of all resuscitations and oxygen administration.
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
See original 2018 Commitment
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
1 |
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
1 |
|
|
New Lives Lost (lives lost – actual lives saved)
0 |
|
|
|
Parrish Medical Center |
Fl |
US |
Anemia and Blood Transfusions
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Commitment
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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 - 12.06.18
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Commitment Update
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Parrish Medical Center
Anemia and Blood Transfusions – Update – 12.06.18
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:
• The patient blood management committee reviews blood utilization, provides transfusion criteria and education to reduce unnecessary transfusions and providing emergent blood needs when necessary. The blood management committee action items include :
• Transfusion not meeting criteria review
• Single unit transfusions
• Implement blood conservation modalities
• Reduction and frequency of blood draws including discard or hold volumes
• Preoperative management of platelet inhibitors and other anticoagulants
• Red cell recovery in the operating room
•Ways to prevent hospital induced anemia via un-necessary blood draws/venipunctures.
Commitment Update:
• The patient blood management committee reviews blood utilization, provides transfusion criteria and education to reduce unnecessary transfusions and providing emergent blood needs when necessary. Inpatient blood transfusions per discharge data are monitored. The goal is less than or equal to 10%.
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
See original 2018 commitment
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
1 |
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
1 |
|
|
New Lives Lost (lives lost – actual lives saved)
0 |
|
|
|
Parrish Medical Center |
Fl |
US |
Venous Thromboembolism (VTE)
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Commitment
×
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 - 12.06.18
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Commitment Update
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Parrish Medical Center
Venous Thromboembolism (VTE) – Update – 12.06.18
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:
VTE risk assessment completed upon admission and daily in electronic health record (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 - monitor for compliance. VTE risk assessment into admission order sets under topic "Nursing assessment and intervention--promote highest level of patient mobility and advance as tolerated." Assess for symptoms/presence of acute DVT and provide intervention. Implement an Early Ambulation Program. Monitor appropriate use of prophylaxis for VTE in patients at high risk.
Commitment Update:
Reinstate a core Multidisciplinary team with in-depth knowledge base of disease process and prevention of VTE; evaluate current practice for chart review and trends--both concurrent and retrospective; Conduct RCA for outliers identified; Identify gaps in care that promote VTE development; evaluate use and type of compression devices as an adjunct to pharmacological solutions; continual EHR evaluation for workflow and feasibility as it pertains to user compliance, ease of use, and change requests based on fall outs.
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
See original 2018 commitment
Impact Details
| Initial Commitment |
Commitment Update |
Project Next Year |
Lives Lost
0 |
Lives Lost
-1 |
Lives Lost:
-2 |
Lives Spared Harm Target
0 |
Actual Lives Spared Harm in last 12 months
0 |
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)
-2 |
|
|
|
Parrish Medical Center |
Fl |
US |
Access To Acute Psychiatric Beds
View Commitment
Commitment
×
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 - 12.06.18
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Commitment Update
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Parrish Medical Center
Access To Acute Psychiatric Beds – Update – 12.06.18
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:
Initiate a core team of multidisciplinary key stakeholders within the community to survey interest, evaluate need, and gain support of a psychiatric bed registry. Evaluate current and future options for a real-time electronic bed tracking systems.
Commitment Update:
Evaluate current technology solutions to include web-based and mobile application psychiatric bed registry that serves as a platform for inpatient hospital bed openings. 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
See original 2018 commitment
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 |
|
|
New Lives Lost (lives lost – actual lives saved)
-1 |
|
|
|
Parrish Medical Center |
Fl |
US |
Resuscitation Optimization
View Commitment
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 - 12.06.18
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Commitment Update
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Parrish Medical Center
Resuscitation Optimization – Update – 12.06.18
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:
PMC's Code Blue Committee is a multi-disciplinary institutional group currently in place primarily responsible for resuscitation programs, with a focus on reducing preventable deaths and ensuring and institutional culture of safety pertaining to optimal resuscitation. Responsibilities include reviewing, revising, or creating protocols following evidence based practice, technology, and performance data, and ensuring training and education to specific provider types and clinical units. Rapid Response Team was also implemented in 2005 to help prevent avoidable deaths in the inpatient setting.
Commitment Update:
The IOM 2001 report on quality in healthcare identified failure to rescue as a key opportunity for improving patient safety, reducing preventable deaths, and decreasing healthcare expenditure. Our commitment is through the use of technology, evidence based practice and collaboration, create a coordinated effort to improve clinical outcomes. PMC's Code Blue Committee is a multi-disciplinary institutional group currently in place primarily responsible for resuscitation programs, with a focus on reducing preventable deaths and ensuring and institutional culture of safety pertaining to optimal resuscitation. Responsibilities include reviewing, revising, or creating protocols following evidence based practice, technology, and performance data, and ensuring training and education to specific provider types and clinical units. PMC will use its existing "Code Blue" Committee as the steering committee for assessing opportunities, identifying and implementing solutions, and gathering/reporting of data pertaining to this APSS (similar to the APSS version of the Resuscitation Outcomes Steering Committee (ROSC)). Code Blue cases and Rapid Response calls will be monitored weekly and any variance will be 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
See original 2018 commitment
Impact Details
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CHOC Children's Hospital |
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8B - Unplanned Extubations in Children
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Commitment
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CHOC Children's Hospital
8B – Unplanned Extubations in Children
Contact Info
Name: James Cappon
Phone: (714) 509-8590
Email: jcappon@choc.org
Position: Chief Quality Officer
Organization Name: CHOC Children's Hospital
Organization Address:
1201 W. La Veta Ave.
Orange, CA 92868 US
Participants:
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Ms. Patricia Huddleson, Manager of Clinical Quality
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Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 8B - Unplanned Extubation
Commitment Name:
8B – Unplanned Extubations in Children
Commitment Start Date:01/01/2017 How Many Hospitals Will This Commitment Represent? 1 Commitment Summary:
Unplanned extubation (UE) of the trachea in children can be a life threatening complication of mechanical ventilation support. These events are by definition sudden, unexpected and have variable outcomes, with a meaningful percentage of patients requiring re-intubation with its associated risks and complications (addressed in PSMF APSS 8A). Both pediatric and adult literature show that adverse effects of UE include increased length of mechanical ventilation and ICU stay, increased risk of pneumonia, increased mortality and increased costs. Reviews of adult UE suggest 10,000 or more associated deaths annually with this adverse event.
Neonates, particularly premature ones, are the most likely pediatric patient to experience UE. This is in part because of their anatomically very short trachea and also due to the general neonatology practice and preference for minimal sedation. Unfortunately, premature infants also physiologically poorly tolerate any dramatic changes in their sensory environment, which certainly includes those of a UE, with adverse vital sign changes persisting for minutes to hours after even seemingly modest inputs such as loud noise or bright light.
UE often occurs in patients who are being prepared to be liberated from mechanical ventilation, which often includes a reduction in sedation. Finding this "sweet spot" between successful conversion to spontaneous breathing while minimizing the risk of UE is a current challenge and focus for many hospitals and healthcare collaboratives. It is also of note that efforts to reduce ventilator-associated events (VAE, previously largely characterized by ventilator-associated pneumonia [VAP]) have also had the seemingly desirable effect of shortening mechanical ventilation duration, but may predispose rapidly weaning patients to the risks of UE or otherwise failed extubation. Commitment Description & Detail:
CHOC Children's has been focused on reducing UE since at least 2011, recognizing the importance of this event at the patient safety and patient and family experience level well ahead of the mainstream movement. UE has been a tracked metric since that time, and efforts at improvement have included standardization of endotracheal tube (ETT) selection, securement, and depth measurements, as well as patient sedation and ETT suctioning protocols.
In 2016, the Children's Hospitals' Solutions for Patient Safety (CHSPS) added UE to its growing collection of pediatric-relevant hospital-acquired conditions (HAC) targeted for reduction. The CHSPS network is a CMS Pay for Performance Hospital Engagement Network (HEN) of some 130 children's hospitals across the U.S. and Canada, and the only one specific to children's care. The overarching aim is the goal of reducing serious harm in children through the reduction of hospital-acquired conditions (HAC). Best practices are identified, and both adherence to these care bundles and outcomes are tracked and benchmarked within the network.
While the incidence of UE at CHOC has dropped gratifyingly over time, events still occur and ongoing vigilance is required. At CHOC, UE rates are tracked monthly and quarterly, and results distributed broadly across the organization. UEs are among the events discussed at the CHOC Daily Safety Briefing; moreover, they have been a longstanding Key Driver of the CHOC high level organizational goal of reducing serious patient harm. All UEs are fully investigated in Apparent Cause Analyses with learnings widely spread.
CHOC will continue its efforts at best practice delivery and clinical outcomes in UE prevention. In alignment with the Patient Safety Movement Foundation's Actionable Patient Safety Solutions (APSS) checklist, CHOC Children's Hospital has successfully completed and implemented the following checklist items. Action Plan:
Unplanned extubation, both in the field and in the hospital, is a common and costly problem, resulting in significant morbidity and mortality.
• Assemble a core multidisciplinary airway safety leadership team
− VP of Quality / Safety
− Physician, nursing, and respiratory care team leaders across all hospital units to ensure recognition of the problem and support development of systems that will eliminate unplanned extubation and its associated complications, especially preventable deaths.
• Determine baseline rate of unplanned extubation (See Metrics Section below).
• Determine baseline rate of complications (oral mucosa and facial skin pressure injuries, pneumonia, vocal cord injury, hypoxemia, brain injury, death) caused by unplanned extubation.
• Perform a root cause analysis (RCA) for all incidences of unplanned extubation.
− Utilize a multidisciplinary team including physicians, nurses and respiratory therapists to evaluate the root cause of every unplanned extubation, determine a plan to eliminate the root cause, implement the plan and track results.
• Implement the core unplanned extubation dataset as defined in the Metrics Section of this APSS.
− Every (endotracheally) intubated, mechanically ventilated patient should have the entire PSMF Core Dataset for extubation recorded in the patient’s medical chart.
− Evaluate your hospital’s Electronic Health Record (EHR) to determine if the entire core dataset is included in the EHR.
o If included, educate all providers of airway management how to properly track UE.
o If not included, contact the EHR company and request they add the dataset; Develop a system for temporarily tracking the dataset until the EHR Company institutes the dataset.
• Develop a Quality Management Process to promote and ensure continuous improvement with an initial goal of eliminating preventable deaths from unplanned extubation and ultimately eliminating all incidences of unplanned extubation.
− Require tracking and reporting of all incidences of unplanned extubation and complications of unplanned extubation (hypoxemia, pneumonia, vocal cord injury, brain injury and death).
• Provide periodic education for all airway management providers.
− Educate providers regarding the importance of prevention of unplanned extubation and the need for accurate data tracking.
− Include unplanned extubation as part of every presentation of management of the difficult airway patient.
• Implement Clinical Best Practices for Preventing Unplanned Extubation.
− Standardize tracheal tube restraint devices, utilizing the most proven methods/devices.
− Implement systems for alerting clinicians to patients with a known difficult airway.
− Formalize systems for appropriate sedation and patient restraint to decrease the risk of unplanned self-extubation.
Commitment Timeline:
CHOC Children's will work with PSMF to update this commitment annually in an ongoing basis.
Impact Details
Lives Saved
Lives Saved predicted:
0.39599999999999985 For reporting purposes, the number has been rounded up to the nearest whole number. Lives Saved predicted:
1
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8A - Safer Airway Management
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Commitment
×
CHOC Children's Hospital
8A – Safer Airway Management
Contact Info
Name: James Cappon
Phone: (714) 509-8590
Email: jcappon@choc.org
Position: Chief Quality Officer
Organization Name: CHOC Children's Hospital
Organization Address:
1201 W. La Veta Ave.
Orange, CA 92868 US
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 8A - Safer Airway Management
Commitment Name:
8A – Safer Airway Management
Commitment Start Date:01/01/2017 How Many Hospitals Will This Commitment Represent? 1 Commitment Summary:
Difficult airways are a fundamental, constant challenge in the care of children, whose anatomy and physiology predispose them to unique approaches and training in airway management. Infants, particularly premature infants, are anatomically the most difficult humans to intubate. In addition, supportive airway and breathing equipment is not always available or even manufactured with the precision of fit and function for all sizes and ages of children. Those healthcare professionals dedicated to the support of ill and injured children are prepared to deal with these realities, but constant evolution of knowledge, preparation and equipment will have a favorable impact on airway safety. Commitment Description & Detail:
A named difficult airway program was begun at CHOC Children's in 2014, with multidisciplinary participation by pediatric critical care, neonatology, anesthesiology, emergency medicine and ENT. This included the creation of difficult airway carts, which contain advanced airway support and visualization equipment. The collaborative approach to improving capability and escalation of response has improved the pathways of approaching and managing the challenging airway patient.
CHOC has a wide breadth of personnel able to assist in difficult airway scenarios, including the 24/7 presence of attending physicians in critical care, neonatology, emergency medicine, trauma surgery and anesthesiology, as well as seasoned leaders in respiratory therapy and nursing.
All airway challenges, including adverse patients events and near misses, are addressed by the organization, with learnings widely shared. CHOC Children's will collaborate with the PSMF to advance its safe airway management program in concordance with the following checklist items. Action Plan:
Failures of airway management (e.g., inability to mask ventilate or oxygenate, unplanned extubation, failure to intubate) are potential major causes of inpatient morbidity and mortality.
• Assemble a core multidisciplinary leadership team to advance airway safety, including: ED, ICU, Hospitalist, ENT and Anesthesiology Physician Leaders.
− ED, ICU Nursing Leaders.
− Respiratory Therapy Leaders.
− Quality Improvement/Safety Leadership (VP or higher level)
• Under the co-leadership of a physician anesthesiologist, develop a comprehensive airway toolkit method (e.g., the Safer Airway Bundle). Start implementation in the ED and ICUs, and then move to floor units and other departments. Include the following Key Components: Failed Airway Path, Airway Cart, Airway Checklist, Quality Assurance, and Team Training.
− Implement Safer Airway Essential Components, as described in Appendix A: Safer Airway Essential Components.
• Require tracking and reporting of “near misses” and complications of airway management.
• Identify adverse outcomes that are iatrogenic and preventable (eg. multiple attempts, esophageal intubation, SpO2 decline of <10%, dental or soft tissue injury).
− Use these case data in medical staff educational sessions to prevent recurrences, as a part of Continuous Quality Improvement (CQI).
• Provide periodic airway management education for all care providers. This will include:
− identification of airway problems,
− selection and use of appropriate intervention, and
− understanding when and how to call for expert assistance (e.g. from Anesthesiology)
Commitment Timeline:
Airway safety in children, including management of the difficult airway, is an essential and evolving aspect of pediatric care. Progress on adherence to the recommendations and best practices contained within this APSS will be tracked annually.
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"We aspire to partner with children and families to deliver what matters to them"
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Commitment
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CHOC Children's Hospital
“We aspire to partner with children and families to deliver what matters to them”
Contact Info
Name: Sandra Schultz
Phone: 7145098683
Email: sschultz@choc.org
Position: Customer Service Manager
Organization Name: CHOC Children's Hospital
Organization Address:
1201 W. LaVeta Ave.
Orange, CA 92868 US
Participants:
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Jim Cappon, MD, Chief Quality & Patient Safety Officer
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 16 - Person and Family Engagement
Commitment Name:
“We aspire to partner with children and families to deliver what matters to them”
Commitment Start Date:07/01/2018 How Many Hospitals Will This Commitment Represent? 1 Commitment Summary:
At CHOC Children's, we believe that the health and well-being of children are dependent upon partnering with families, those who surround, comfort, love, and are responsible for the child. To meet the unique needs of each child, we will partner with families in designing individual health care that honors and respects their beliefs, culture, values, and knowledge. We will encourage their questions and contributions, respect their choices, and strive to ease stress upon families of children who seek our support. When it comes to delivering high quality, safe care and exceptional experience, we will improve our communication, build stronger relationships, enhance our practices and systems that involve patient and family participation to ensure safety. Our process for identifying experience gaps will involve patients and families to create goals that will deliver a great care experience. Commitment Description & Detail:
Effective shared communication among patients, parents and the care team continue to be a top priority for both our organization and our families. The resulting coordination of care and improved communication produces better health outcomes and a more positive experience of care. Our approach to help minimize the communication breakdown that can occur among the care team, is to provide our associates with the skills and strategies that will help them connect through Relationship-Centered Care, recognizing emotions and responding with relations, human connection and empathy. Our hospital - wide improvement efforts have extended to include a committed core of volunteer Parent Advisory Council members who sit as active participants who collectively contribute their time attending monthly meetings, bringing to the table the patient/parent and family voice. This year, they have set a committee goal to collaborate with hospital associates in this initiative, which includes, parents, patients, nurses, doctors, ancillary services, and front-line associates on the development of a parent/healthcare team communication video. This will become part of the hospital’s new associate onboarding process and will be presented at various hospital forums. The goal of this parent - driven communication video will help enhance the partnership between the patient/parent and the healthcare team from the patient/parent perspective. Caring with kindness, compassion, listening and understanding the child and family a whole is “complete care” which is what we strive to provide. Action Plan:
Person and family engagement – often referred to as “PFE” – is an underutilized resource for achieving the goal of zero harm. An effective program to implement and sustain PFE should include the following actionable steps:(HRET, n.d.).
• Ensure that all members of the care team listen to the person and their family members’ questions and concerns, and avoid being short or curt with patients,
• Assess strengths and gaps in your organization’s PFE efforts by using this checklist:
− Elicit feedback from your senior leadership team, staff, patients and families about PFE efforts.
Inventory policies, processes, position descriptions and training programs to determine whether PFE is included.
− Discuss findings and conclusions with leadership, staff and patients to create awareness and lay the groundwork for improvement efforts.
• Deploy a system to implement PFE and monitor progress on improving PFE using the following:
− Develop an infrastructure that brings the patient and family voice systemically into your patient safety improvement work, such as:
o Appoint persons who identify as patients or patient advocates to your governing body,
o Establish patient and family advisory bodies that contribute to organizational safety initiatives,
o Include patient advocate input into improvement committees or root cause analysis teams, and/or
o Establish a functional area within your organization whose role and accountability is to engage patients and families.
− Select measures that will allow you to see whether processes and patient safety outcomes are changing.
− Ensure systems are in place so that needed data can be collected and shared.
− Compile results in a format that is easy to understand and monitor.
− Share results with staff, senior leadership, board, community and public.
Our commitment to our patients and their families is to improve their overall CHOC experience and provide exceptional care. To achieve this goal, we will utilize the 4 core concepts of Patient - and Family - Centered Care as our guiding principles: Respect and Dignity, Collaboration, Participation and Information Sharing. We will track and trend our improvement efforts utilizing our patient experience survey scores and feedback. Patient experience scores and feedback are disseminated throughout the organization monthly, quarterly and annually and publicly displayed on CHOC’s Communication/Quality and Patient Safety Boards. The survey measures used for tracking are organizational progress will be the following:
1. Using any number from 0 to 10, where 0 is the worst hospital possible and 10 is the best hospital possible, what number would you use to rate this hospital during your child's stay?
2. During this hospital stay, how often did your child's doctors/nurses/providers treat you with courtesy and respect?
3. During this hospital stay, how often did your child's doctors/nurses/providers listen carefully to you?
4 During this hospital stay, how often did your child's doctors/nurses/providers explain things to you in a way that was easy to understand?
Actionable Steps
• Mandatory 4-hour training sessions for all new hires within 90 days, “Living the Value of Service” (parent video)
• Physician resident training forums, Advocacy, Child Abuse, Community, and Teaching, (ACT 1) Pediatric Resident Rotation (parent video)
• Registered nurse resident, Service Excellence, Clinical Orientation (parent video)
• New volunteer orientation, “Living the Value of Service training for Volunteers” (parent video)
• Communication video will be made available on CHOC’s intranet to be used during any departmental training session (parent video)
• 4-hour skills practice session for providers, “RELATIONS For Healthcare Transformation” (effective communication in creating a culture of excellence)
CHOC Children’s will continue to utilize the Patient Safety Movement Executive Summary checklist recommendations in conjunction with its internal plans.
Commitment Timeline:
Implemented by June 30, 2019
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Providing Triage and Intervention to Primary Psychiatric Patients Presenting to the Emergency Department
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Commitment
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CHOC Children's Hospital
Providing Triage and Intervention to Primary Psychiatric Patients Presenting to the Emergency Department
Contact Info
Name: Heather Huszti
Phone: (714) 509-8481
Email: hhuszti@earthlink.net
Position: Chief Psychologist
Organization Name: CHOC Children's Hospital
Organization Address:
1201 West La Veta Ave
Orange, CA 92868 US
Commitment Details What Patient Safety Challenge does your Commitment address?
Commitment Name:
Providing Triage and Intervention to Primary Psychiatric Patients Presenting to the Emergency Department
How Many Hospitals Will This Commitment Represent? 1
Action Plan
1.) Identified and hired a licensed psychologist who had previous training in implementing an intensive mental health intervention in ED’s along with a licensed social worker who also had experience in acute psychiatric crises
2.)Training provided by the Orange County Healthcare Agency to allow staff access to county based services (to make appointments and recommendations)
3.) Adjust EMR to allow for specialized charting and tracking of patients
4.) Mental health team will see patients as soon as they are roomed and begin evaluation and intervention, will make appropriate recommendations to the family, and will work with the medical team to provide clearance for the patient when possible or to find inpatient placement if warranted
5.) Receive additional training in intensive mental health intervention designed for patients with psychiatric disorders who present in the ED from Dr. Wharff, Boston Children’s Hospital
6.) Provide ongoing education and consultation to medical staff in ED regarding service and how it works
7.) Staff provide coverage 8 hours per day, 6 days per week at present.
Commitment Timeline
Began in April 2016. Acceptance by families and patients has been high. Acceptance by medical staff has also been high. Data being gathered includes, length of time in ED, percent transferred to inpatient psychiatric unit, percent discharged home, patient engagement in treatment at one week follow-up call, returns to ED within 1 month, hospitalization in psychiatric unit within 1 week of discharge, and suicide attempts within 1 week of discharge.
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:
Multiplying the rate of youth suicide for Orange County (6.4) per 100,000 by the population in Orange County of children under 18 years of age (approximately 750,000).
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Averting Severe Pediatric Adverse Drug Events Through Increased Utilization of Smart Pump Drug Libraries for Intravenous Medications
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Commitment
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CHOC Children's Hospital
Averting Severe Pediatric Adverse Drug Events Through Increased Utilization of Smart Pump Drug Libraries for Intravenous Medications
Contact Info
Name: Grace Magedman
Phone: 714-509-4332
Email: gmagedman@choc.org
Position: Director of Pharmacy Services
Organization Name: CHOC Children's Hospital
Organization Address:
1201 W. La Veta Avenue
Orange, CA 92868 US
Participants:
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Shannon Bertagnoli, Pharmacy Medication Safety and Quality Coordinator
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 3D - Pediatric Adverse Drug Events
Commitment Name:
Averting Severe Pediatric Adverse Drug Events Through Increased Utilization of Smart Pump Drug Libraries for Intravenous Medications
Commitment Start Date 11/01/2016 How Many Hospitals Will This Commitment Represent? 1
Action Plan
The smart pump oversight committee will continue to meet quarterly, and data obtained will continue to be utilized to adjust the drug libraries to maximize safe use and minimize program errors. Severe adverse drug events averted and potential costs avoided will be monitored along with this data. Good catches and nursing education on common errors or near misses observed will be disseminated quarterly also.
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:
This value is based on the number of infusions reprogrammed, cancelled infusions, and severe ADEs averted, which is monitored on a quarterly basis.
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Improving Hand Hygiene rate in the NICU by 20%
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Commitment
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CHOC Children's Hospital
Improving Hand Hygiene rate in the NICU by 20%
Contact Info
Name: Sudeep Kukreja
Phone: (714) 585-1920
Email: sudeepmd@yahoo.com
Position: Director of CHOC NICU at SJH
Organization Name: CHOC Children's Hospital
Organization Address:
455 S. Main Street
Orange, CA 92868 US
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 2A - Hand Hygiene
Commitment Name:
Improving Hand Hygiene rate in the NICU by 20%
How Many Hospitals Will This Commitment Represent? 1
Action Plan
1. Share the current hand hygiene compliance rate in the NICU with everyone involved in the care of babies in our NICU
2. Buy in from all the stakeholders.
3. Education of everyone involved in the care of babies in our NICU
Commitment Timeline
One 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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Preventing Patient Deterioration
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Commitment
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CHOC Children's Hospital
Preventing Patient Deterioration
Contact Info
Name: James Cappon
Phone: (714) 509-7814
Email: jcappon@choc.org
Position: Medical Director of Quality and Patient Safety
Organization Name: CHOC Children's Hospital
Organization Address:
1201 W. La Veta Ave.
Orange, CA 92868 US
Participants:
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Anthony Chang, Cardiology Division Chief
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Matthew Gerlach, Executive Vice President and Chief Operating Officer
Commitment Details What Patient Safety Challenge does your Commitment address?
Commitment Name:
Preventing Patient Deterioration
How Many Hospitals Will This Commitment Represent? 1
Action Plan
Active interventions included: 1) the development of a Rapid Response Team, to bring critical care assistance to the bedside of a worsening non-ICU patient, which included the ability of patient families to call for such help; 2) proactive identification and night time rounding on patients felt to be most at risk; and 3) the implementation of a Pediatric Early Warning System (PEWS), in which all non-ICU patients are monitored for standardized physiological status and that status is continuously displayed on unit electronic whiteboards and in the EHR for local and/or remote viewing.
Commitment Timeline
We are gratified by this improvement in patient safety for our patients and families. Furthermore, we believe that the stabilized rate represents the true baseline status of non-preventable non-ICU codes in hospitalized U.S. children (examples of such events are sudden apnea, seizures and adverse drug reactions). The CHOC Children’s ongoing commitment is to further study this vulnerable group of patients, typically either very young or with complex medical disease, to determine if this rate can in fact reach zero. This program is but one example of the substantial patient safety successes achieved within the U.S. medical industry, upsetting the previously widely held notion that “getting to zero” was simply not reasonable.
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:
Following the above interventions, the CHOC Children’s Non-ICU Code rate declined substantially from a baseline of 0.8 codes/1000 patient days to 0.1 codes/1000 patient days, a reduction of 87%, which has been stable for five years. This represents a potential annual event avoidance of 45 codes per year. Moreover, although most pediatric codes are respiratory in nature, we have even further reduced non-ICU cardiac resuscitations-with their associated poor prognosis, with only one such event in the last 1500 days.
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Preventing Patient Deterioration - Update - 10.15.18
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Commitment Update
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CHOC Children's Hospital
Preventing Patient Deterioration – Update – 10.15.18
Contact Info
Name: James Cappon
Phone: (714) 509-8590
Email: jcappon@choc.org
Position: Chief Quality Officer
Organization Name: CHOC Children's Hospital
Commitment Details Commitment Start Date: 01/01/2013 How many hospitals are represented in this commitment?
Action Plan:
Active interventions included: 1) the development of a Rapid Response Team, to bring critical care assistance to the bedside of a worsening non-ICU patient, which included the ability of patient families to call for such help; 2) proactive identification and night time rounding on patients felt to be most at risk; and 3) the implementation of a Pediatric Early Warning System (PEWS), in which all non-ICU patients are monitored for standardized physiological status and that status is continuously displayed on unit electronic whiteboards and in the EHR for local and/or remote viewing.
Commitment Update:
The CHOC Children's program to reduce non-ICU resuscitations quickly expanded backward in time to identify children in earlier and earlier stages of clinical deterioration. This primarily occurred via the serial implementation in Years 1 and 2 of a Rapid Response Team (RRT) and Pediatric Early Warning System (PEWS), respectively. Subsequently, family members were brought into the fold and educated at patient admission that they could initiate RRTs of their own accord. The most important change, however, was that of culture, where hospital staff of all levels came to find non-detected and/or non-escalated patient deterioration as fundamentally unacceptable, which further advanced the pace, breadth and intensity of all efforts.
The gratifying overall result is that the CHOC Non-ICU Code Rate dropped approximately 85% in the first two years of the program and has remained at that low level for the past 10 years. This means that hundreds of children have avoided preventable respiratory, cardiac and neurologic arrests. Moreover, millions of dollars of unnecessary healthcare costs have been avoided.
Your commitment aligns with APSS
1 (Culture of Safety), 4 (Failure to Rescue), 9 (Early Detection of Sepsis) Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
Changing culture to a state in which early detection of and response to deterioration are the only acceptable workflows is the key to success. So built-in is this mentality that even a small blip in our Non-ICU Code Rate leads to considerable investigation and process improvement.
The past year, for example, led to the development of and initiation of a "Watcher Program," where patients who have subtle changes, perhaps even prior to their PEWS score changing and/or well-before meeting RRT criteria, are identified as "Watchers," or children bearing watching. A bedside multidisciplinary huddle (including family) is initiated, a mitigation plan created, and a follow up done at 2 hours to see if the desired outcomes have been achieved. Early results show an increase in RRTs, a decrease in RRTs requiring ICU transfer, and a reduction in Non-ICU Code Rate.
Impact Details
| Initial Commitment |
Commitment Update |
Project Next Year |
Lives Lost
0 |
Lives Lost
0 |
Lives Lost:
-45 |
Lives Spared Harm Target
0 |
Actual Lives Spared Harm in last 12 months
51 |
Lives Spared Harm Target for following calendar year
48 |
Lives Saved Target
0 |
Actual Lives Saved in last 12 months (might differ from initial target)
45 |
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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Challenge 2B - CAUTI Prevention
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Commitment
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CHOC Children's Hospital
Challenge 2B – CAUTI Prevention
Contact Info
Name: James Cappon
Phone: (714) 509-8590
Email: jcappon@choc.org
Position: Chief Quality Officer
Organization Name: CHOC Children's Hospital
Organization Address:
1201 W. La Veta Ave.
Orange, CA 92868 US
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 2B - Catheter-associated Urinary Tract Infections (CAUTI)
Commitment Name:
Challenge 2B – CAUTI Prevention
Commitment Start Date:01/01/2013 How Many Hospitals Will This Commitment Represent? 1 Commitment Summary:
Catheter-associated urinary tract infection (CAUTI) is a frequent and potentially severe healthcare-acquired infection (HAI). It is the second most common HAI in children, after lower respiratory tract infection, e.g., pneumonia. CAUTI can lead to sepsis, particularly in those at the extremes of age or with underlying complex or chronic medical conditions. As a tertiary-quaternary regional children's hospital, CHOC Children's has long been trying to achieve the right balance between urinary catheter usage for high quality care and the risks of related complications.
Evolving medical knowledge and practice has led to the development of best practices for urinary catheter management, including placement, maintenance care, and timely discontinuation. CHOC aims to continue and advance these practices in conjunction with the Patient Safety Movement Foundation to reduce and eliminate CAUTIs and their consequences. Commitment Description & Detail:
CHOC Children's has been preventing catheter-associated urinary tract infections since well before 2013, when our formal involvement with the Children's Hospitals' Solutions for Patient Safety (CHSPS) began. The CHSPS network is a CMS Pay for Performance Hospital Engagement Network (HEN) of some 130 children's hospitals across the U.S. and Canada, and the only one specific to children's care. The overarching aim is the goal of reducing serious harm in children through the reduction of hospital-acquired conditions (HAC).
CAUTI is one of the more frequent HACs, including in children. Due to focus on catheter management best practices (both insertion and maintenance) as well as effective efforts to reduce the duration of time urinary catheters are in place, the incidence has dropped gratifying over time; however, events still occur and ongoing vigilance is required. As part of the vigorous Infection Prevention program at CHOC, CAUTI rates are tracked monthly and quarterly, and results distributed broadly across the organization. Tellingly, the "days since last" CAUTI is announced each morning at the CHOC Daily Safety Briefing.
CHOC will continue its efforts at best practice delivery and clinical outcomes in CAUTI prevention. In alignment with the Patient Safety Movement Foundation's Actionable Patient Safety Solutions (APSS) checklist, CHOC Children's Hospital has successfully completed and implemented the following checklist items.
Action Plan:
Catheter-associated Urinary Tract Infections (CAUTI) are a frequent cause of morbidity and mortality in hospitals.
• Insert catheters only for appropriate indications
• Ensure that only properly trained persons insert and maintain catheters
• Insert catheters using aseptic technique and sterile equipment
• Perform perineal care routinely for patients who have indwelling catheters to reduce the risk of skin breakdown and irritation
• Remove catheters as soon as possible
• Following aseptic insertion, maintain a closed drainage system
• Select technology has shown early success to reduce infections and positively enhance outcomes of patients
Commitment Timeline:
The CHOC commitment to CAUTI reduction is ongoing and will be reported annually.
Impact Details
Lives Saved
Lives Saved predicted:
0.022999999999999985 For reporting purposes, the number has been rounded up to the nearest whole number. Lives Saved predicted:
1
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Challenge #2A: Hand Hygiene
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Commitment
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CHOC Children's Hospital
Challenge #2A: Hand Hygiene
Contact Info
Name: James Cappon
Phone: 7145098590
Email: jcappon@choc.org
Position: Chief Quality Officer
Organization Name: CHOC Children's Hospital
Organization Address:
1201 W. La Veta Ave.
Orange, California 92868 US
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 2A - Hand Hygiene
Commitment Name:
Challenge #2A: Hand Hygiene
Commitment Start Date:07/01/2013 How Many Hospitals Will This Commitment Represent? 1 Commitment Summary:
The lack of consistent, appropriate hand hygiene in all patient care areas can be considered a “medical error” that can result in avoidable infections, morbidity and mortality. The World Health Organization (WHO) continues to describe hand washing as the most effective way of preventing the spread of infections.
In order to implement a program to improve hand hygiene and reduce HAIs, CHOC Children's has been actively engaged in a hand hygiene surveillance and performance improvement plan that has required actionable steps. This has required substantial enterprise-wide commitment to awareness, education and tracking. With this, organization-wide hand hygiene compliance for the recently completed fiscal year was 96%. Commitment Description & Detail:
The measurement of hand hygiene performance proves to be quite difficult. Self-reporting is notoriously optimistic, "secret shopper" methodology can introduce bias and is hampered by logistics, and technologic modalities are in early stages and in the case of pediatrics, unproven and largely untested. Remote video observations, akin to cardiac telemetry, are fraught with similar human factors limitations.
Given the above, for the past 7 years, CHOC has used a secret shopper observation methodology of hand hygiene "5 Moments" compliance, which technologic solutions cannot fully capture at this time. Results are reported and widely displayed by unit and role, including in Communication Boards in each unit. Patients, families and visitors can view this data. Last year's high performance was garnered from over 3500 blinded observations, and is part of a 7 year improvement trend. Ongoing education of staff, physicians, volunteers and families and visitors is an integral aspect of this performance improvement project.
CHOC Children's has offered to be a willing partner in pilot projects to test additional techniques of hand hygiene compliance measurement in children.
In alignment with the Patient Safety Movement Foundation's Actionable Patient Safety Solutions (APSS) checklist, CHOC Children's Hospital is continuously improving hand hygiene compliance and surveillance system plan and will report our results on an annual basis. Action Plan:
• Accountability for Performance Improvement at facility and unit leadership levels as part of an overall Organizational Hand Hygiene Guideline. Ensure that alcohol-based hand rubs and soap are available as close to the point of care as possible.
• Establish a multi-disciplinary hand hygiene team responsible for implementation of the Hand Hygiene Protocol, including nursing, physicians, infection preventionists and administration.
• The protocol must include mandatory training for all healthcare workers (HCWs) upon hire and at least once annually.
• Training to include:
• Proper technique for hand rubbing and soap and water washing
• Indications for hand rubbing vs soap and water washing (WHO or CDC Guideline)
• How to speak up when fellow HCWs do not comply.
• Education for patients, family members and visitors.
• Performance Evaluation and Feedback
• Hand hygiene compliance must be measured using a validated method of capturing and reporting all hand hygiene events. Such compliance systems have been shown to lead to sustainable improvement, reduced infections and costs and a positive impact on patient safety culture (Bouk, Mutterer, Schore and Alper, 2016) (Kelly, Blackhurst, McAtee and Steed, 2016)(Michael, Einloth, Fatica, Janszen and Fraser, 2017)(Son et al., 2011).
• Provide performance feedback to unit leadership and frontline staff on a regular basis, using evidence-based behavior change feedback models (Welsh, Flanagan, Hoke, Doebbeling and Herwaldt, 2012).
• Reminders in the workplace, such as posters, brochures, leaflets, badges, stickers, can be used, provided they are consistent with the overall Hand Hygiene Protocol.
- Regarding direct monitoring of hand hygiene compliance through hand hygiene monitoring technologies:
- CHOC research found no pediatric experience with three compliance technology vendors, and thus volunteered to be a pediatric test site for evidence-based investigations. At this time, the value has not been established for this methodology in the pediatric population. Commitment Timeline:
This implementation plan has been in place at CHOC Children's for over a decade and our commitment will be ongoing and reported annually.
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APSS #9: Early Detection and Treatment of Sepsis
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CHOC Children's Hospital
APSS #9: Early Detection and Treatment of Sepsis
Contact Info
Name: James Cappon
Phone: 17145098590
Email: jcappon@choc.org
Position: Chief Quality Officer
Organization Name: CHOC Children's Hospital
Organization Address:
1201 W. La Veta Ave.
Orange, California 92868 US
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 9 - Early Detection and Treatment Of Sepsis
Commitment Name:
APSS #9: Early Detection and Treatment of Sepsis
Commitment Start Date:01/01/2016 How Many Hospitals Will This Commitment Represent? 1 Commitment Summary:
Sepsis extracts a high toll of morbidity and mortality in children and adults alike. It is the leading cause of death in hospitalized children, claiming as many as 5,000 lives each year. Tens of thousands more children are treated for annually for sepsis, but that's not the end of it - at least half of survivors will be readmitted and over one-third of survivors of severe sepsis will develop a long term disability. The vast majority of pediatric sepsis is treated in a pediatric intensive care unit, and each hospitalization costs approximately $75,000. Nationally, sepsis has been estimated to consume 16% of pediatric inpatient expenditures.
As one approach, CHOC Children's Hospital is one of some 50 national children's hospitals working together to both improve outcomes and reduce the incidence of severe sepsis and septic shock in children. We aim to reduce the incidence of severe sepsis and septic shock by 75% in three years locally and nationally, including the onset of hospital-onset sepsis. By increasing the awareness, detection and response to early findings of sepsis in children, we aim to decrease mortality by an additional 75% as well. Sepsis is often treatable, but early detection and action are key. The stakes are high to master the collective approach to this oft-understood and frequently very serious illness. Commitment Description & Detail:
CHOC is basing many of its efforts with the Children's Hospital Association Improving Pediatric Sepsis Outcomes (IPSO) national collaborative. In this collaborative, best practices, monthly data submissions, and benchmarked reports for quality improvement and outcome enhancement are integrated locally and nationally over at least the next three years. An inpatient program is rolling out including efforts across the continuum from ED to medical, surgical and oncology wards, to intensive care units. These activities are in concert with those of the PSMF Sepsis APSS, with its details described herein.
One specific tactic of the CHOC plan is the use of Sepsis Huddles when there are strong criteria (3 or more electronic triggers) or other suspicion of sepsis. This briefing includes the immediate clinical caregivers at the bedside and includes the formulation of an action plan. Parents and guardians are a part of that gathering, as possible. Furthermore, when possible, specific indicators of possible sepsis will be included in CHOC's already robust program to detect and prevent clinical deterioration, including non-ICU codes.
In alignment with the Patient Safety Movement Foundation's Actionable Patient Safety Solutions (APSS) checklist, CHOC Children's Hospital is actively working on the below checklist items. Action Plan:
-Commitment from hospital governance and senior administrative leadership to support early detection and appropriate management of sepsis in their healthcare system.
-Develop a team approach to implement a protocol for early sepsis identification and treatment.
-Appoint an MD chairperson to be responsible and accountable for leading this group.
-CHOC participates in the Children's Hospitals Association Improving Pediatric Sepsis Outcomes (IPSO) national collaborative to reduce severe sepsis by 75%
-CHOC IPSO structure includes Steering, Operations and Unit-based committees
-Implement a Sepsis Rapid Response Team or incorporate early detection of sepsis into your existing medical emergency teams (e.g. Rapid Response Teams).
-Formalize a process to screen patients for signs of sepsis throughout the entire institution. (In progress, although PEWS and RRT criteria also capture the bulk of these)
-IPSO screening currently in place in ED
-Expands to Hematology-Oncology and wards this year
-Implement an effective monitoring system to accomplish continuous monitoring and notification based on acute changes to the following patient data:
o Fever or Hypothermia (temperature age-based norms for pediatric populations);
o Tachypnea per age-based norms for pediatric populations;
o Altered mental status;
o Hyperglycemia (per pediatric normative values) in the absence of diabetes;
o Leukocytosis or Leukopenia per age-based norms. Normal WBC count with greater than 10% immature forms;
o Plasma C-reactive protein above the standardized value;
o Plasma procalcitonin more than two standard deviations above the normal value (N/A currently at CHOC);
o Hypotension per age-based pediatric norms;
o Hypoxemia;
o Acute oliguria (per pediatric norms);
o Thrombocytopenia;
o Hyperlactatemia (> 2mmol/L [CHOC Children's Lab]); or
o Prolonged capillary refill time or mottling.
-Select an EHR to serve as a data collection tool and repository for predicting risk of sepsis for patients. A system that provides a data collection tool and allows for continuous analysis and surveillance will be most beneficial.
-Implementation of automated electronic screening based on existing data (SIRS criteria, MEWS or any other warning system being used).
-CHOC has used the Pediatric Early Warning System (PEWS) for all inpatients since 2009.
-Design a workflow specific to level of alert: (In progress)
o SIRS met – assess for infection.
o If patient has sepsis – increase monitoring or assessment for presence of severe sepsis.
-Implement a process for continuous monitoring of electronic systems and protocols: (In progress)
o Compliance, efficacy and outcome measures.
-Implement case reviews for outliers.
-For severe sepsis:
-Implement workflow for rapid assessment and intervention at the bedside.
-Initiate severe sepsis bundle (3 hour elements):
-Obtain blood cultures prior to administration of antibiotics.
-Administer broad spectrum antibiotics.
-Administer appropriate volume expansion for hypotension or lactate ≥4 mmol/L.
-Build electronic documentation of process of care (fluids, antibiotics, clinical assessment etc.).
-For septic shock:
o Implement workflow for rapid assessment, intervention and need for higher level of care.
-Initiate septic shock bundle (6 hour elements):
-Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation to maintain a mean arterial pressure [MAP] ≥ low normal range for age).
-In the event of persistent hypotension despite volume resuscitation (Septic Shock) or initial lactate ≥4 mmol/L (36 mg/dL):
-Measure central venous pressure (CVP).
-Measure central venous oxygen saturation (ScvO2).
-Remeasure lactate if initial lactate was elevated.
Commitment Timeline:
CHOC Children's will continue to work on these checklist items, international bundle elements and more in our sepsis prevention program. Our commitment to this disease and APSS is strong, ongoing, and will be reported to PSMF annually.
Impact Details
Lives Saved
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APSS #10: Reducing Non-ICU Codes
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CHOC Children's Hospital
APSS #10: Reducing Non-ICU Codes
Contact Info
Name: James Cappon
Phone: 17145098590
Email: jcappon@choc.org
Position: Chief Quality Officer
Organization Name: CHOC Children's Hospital
Organization Address:
1201 W. La Veta Ave.
Orange, California 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: Reducing Non-ICU Codes
Commitment Start Date:07/01/2008 How Many Hospitals Will This Commitment Represent? 1 Commitment Summary:
Reducing preventable deaths by recognizing the early signs of pediatric deterioration requires a multi-disciplinary, multi-specialty collaborative team. CHOC Children's began work on this topic nearly a decade ago by proof of concept (which was positive), followed by implementation of a Rapid Response Team, Pediatric Early Warning System, and more recently, a "Watcher Program," each focusing on ever-earlier detection and mitigation of patient deterioration. Commitment Description & Detail:
In the first two years of the Reducing Non-ICU Codes effort, non-ICU codes dropped by 85%. Gratifyingly, they have remained at this lower rate for the past 9 years. As an example, there were only 6 total non-ICU arrests last fiscal year. Moreover, the great bulk of the remaining events are respiratory events; cardiac arrests have become vanishingly small. As an example of the latter, CHOC has achieved one interval of >1000 days between Non-ICU cardiac arrests.
We calculate there have been 433 avoided codes in hospitalized CHOC children since the inception of this effort.
In alignment with the Patient Safety Movement Foundation's Actionable Patient Safety Solutions (APSS) checklist, CHOC Children's Hospital has completed and implemented the below checklist items.
Action Plan:
-An institutional resuscitation outcome program should target preventable deaths for a particular hospital or healthcare organization.
-A multi-disciplinary institutional group should be designated as primarily responsible for the resuscitation program.
-The CHOC Code White Committee oversees resuscitation and related escalation and deterioration detection and prevention activities
-A formal mechanism for input data (Afferents) should be identified. This should include both external sources of information, such as guidelines and scientific literature, as well as internal (institutional) data.
-The institutional ROSC should have input into the Efferent actions in response to Afferent data and perceived institutional resuscitation needs.
- An effective resuscitation program will engage individual providers and enhance their personal sense of ownership and accountability. Ultimately, this program should become the primary vehicle to reduce preventable deaths and ensure an institutional culture of safety.
-Outcome data should be presented to the hospital medical executive board bimonthly.
-An organized approach to data collection and performance improvement should target various etiologies of cardiopulmonary arrest with regard to reducing arrest incidence, increasing arrest survival and improving end-of-life discussions with patients and families.
-Institutional resuscitation protocols should consider available evidence, technology, and performance improvement data.
-Provider training should ensure optimal resuscitation performance and be specific to provider type and clinical unit.
-Cardiopulmonary arrest resuscitation should emphasize optimal chest compressions and controlled ventilations as recommended by the AHA in their ACLS protocol.
-Post-resuscitative care should focus on optimizing supportive critical care and consideration of age-appropriate temperature management.
-End-of-life discussions should provide patients and families with compassionate but realistic expectations regarding goals of therapy and various therapeutic options.
-Cardiopulmonary arrest prevention should emphasize early recognition of the deteriorating patient by technology that can present an early warning system.
-Perfusion technologies include sphygmomanometry, ECG, capnometry, clinical assessment (mental status, capillary refill, pulse quality, extremity temperature), pulse oximetry including
related perfusion indices, laboratory measures of acidosis (pH, base deficit, lactate, anion gap), and newer modalities (near-infrared spectroscopy, heart-rate
variability).
-Oxygenation technologies include pulse oximetry, blood gas analysis, near-infrared spectroscopy, and clinical assessment.
-Ventilation technologies include respiratory volumetrics (tidal volume, respiratory rate), blood gas analysis, capnometry, capnography, apnea monitoring, transcutaneous CO2 monitoring, and clinical assessment. Commitment Timeline:
CHOC Children's will report progress to the PSMF on eliminating preventable Non-ICU codes and deaths on an annual basis. Our commitment to this topic and APSS will be ongoing.
Impact Details
Lives Saved
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APSS #12A: Venous Thromboembolism (VTE)
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CHOC Children's Hospital
APSS #12A: Venous Thromboembolism (VTE)
Contact Info
Name: James Cappon
Phone: 17145098590
Email: jcappon@choc.org
Position: Chief Quality Officer
Organization Name: CHOC Children's Hospital
Organization Address:
1201 W. La Veta Ave.
Orange, California 92868 US
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 12A - Venous Thromboembolism (VTE)
Commitment Name:
APSS #12A: Venous Thromboembolism (VTE)
Commitment Start Date:01/01/2015 How Many Hospitals Will This Commitment Represent? 1 Commitment Summary:
Current research and quality improvement work is uncovering that VTE is not just a disease of adults. The nature of most pediatric disease is venous thrombosis rather than embolism, although detection of the latter can be challenging. The majority of non-adolescent pediatric VTE disease is related to central lines, due to a combination of the catheter itself, which by definition occupies a greater proportion of the patient vessel lumen, and the underlying clinical state requiring the line to be in place. Adolescent VTE pathophysiology becomes more similar to that seen in adults, with similar risk factors and presentation.
In order to establish a program to eliminate VTE, an implementation plan with the following actionable steps is recommended as best practice science to reduce patient harm. The following core action items and prevention strategies are outlined below using an interdisciplinary, best practice approach.
Commitment Description & Detail:
CHOC participates as a member of the Children's Hospitals' Solutions for Patient Safety (CHSPS) network, a CMS Pay for Performance Hospital Engagement Network (HEN) of some 130 children's hospitals across the U.S. and Canada, with the goal of reducing harm in children. CHOC is a Pioneer Group member of the Venothromboembolism (VTE) hospital-acquired condition (HAC), which has identified that VTE is indeed a pediatric entity, and one of the most common HACs in overall incidence. This group is identifying both the incidence and early aspects of best practice prevention and therapy for the pediatric population.
CHOC uses an internally developed VTE risk assessment tool on all patients 12 years and older, which is mandated to be used at admission, transfer to a different care level setting, and/or every 7 days. Risk stratification leads to linked recommendations for EHR ordering of scaled VTE prophylaxis. VTE events and rates are measured monthly locally and across the network.
In alignment with the Patient Safety Movement Foundation's Actionable Patient Safety Solutions (APSS) checklist, CHOC Children's Hospital has successfully completed and implemented the following checklist items.
Action Plan:
-Hospital governance and senior administrative leadership must champion efforts in raising awareness around the high incidence of VTEs and prevention strategy measures.
-Healthcare leadership should support the design and implementation of standards and provider training programs on VTE reduction and prevention strategies by:
• Accurately stratifying risk by ensuring that providers perform a VTE risk assessment
• Measure appropriate quality measures related to VTE to close performance gap
• Complete in depth chart review for hospital-associated thrombosis events to identify opportunities for improvement and then acting on lessons learned
• Adhere to VTE best practices from national organizations such as Agency for Healthcare Research and Quality’s VTE Safety Toolkit. The toolkit contains 10 components that are evidence-based guidelines for preventing, diagnosing, treating, and educating patients and providers about VTE. The components are as follows:
-VTE prophylaxis guidelines, VTE risk assessment tool, VTE treatment pathway
-Creating of a standardized inpatient anticoagulant order set
- CHOC belongs to the Children’s Hospitals’ Solutions for Patient Safety (CHSPS) VTE Pioneer Group, developing and monitoring VTE practice and events in North American children
-Ensure healthcare professionals receive, at the least, annual training on new VTE policies and processes
- Assess risk for VTE among patients hospitalized with:
o Injury to vein: fracture, surgery
o Slow blood flow: bedrest, limited mobility, paralysis
o hormone replacement therapy
o Chronic illness: cancer, heart/lung disease, inflammatory bowel disease, kidney disease;
o Other: personal or family history of DVT/PE, obesity, central lines, or clotting disorders.
-Educate patient and families on VTE risks, complications, and importance of mechanical and medication prophylaxis.
-Select technologies that show early evidence to reduce VTEs and positively impact both patient and provider outcomes in the clinical settings
-Implement an EHR with prompt decision making support to ensure that every appropriate patient has a valid VTE prevention plan in place at all times during their hospitalization.
Commitment Timeline:
The CHOC commitment to VTE reduction is ongoing and will be reported annually.
Impact Details
Lives Saved
Lives Saved predicted:
0.5616 For reporting purposes, the number has been rounded up to the nearest whole number. Lives Saved predicted:
1
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APSS #13: Mental Health
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CHOC Children's Hospital
APSS #13: Mental Health
Contact Info
Name: James Cappon
Phone: 17145098590
Email: jcappon@choc.org
Position: Chief Quality Officer
Organization Name: CHOC Children's Hospital
Organization Address:
1201 W. La Veta Ave.
Orange, California 92868 US
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 13B - Collaborative Care Planning in Mental Health
Commitment Name:
APSS #13: Mental Health
Commitment Start Date:07/01/2018 How Many Hospitals Will This Commitment Represent? 1 Commitment Summary:
Children's mental health is as important as their physical health. It is not always obvious when a child is struggling emotionally, but recognizing the symptoms and seeking early and effective mental health services are important for long-term health. As at least one in five children will experience a mental health challenge while growing up, the issue is critical. Stories of courageous children battling medical illnesses abound, yet the mental health crisis is much more shrouded in secrecy. The result? Only one-third of children receive the mental health services they need. And suicide is the second leading cause of death between 10 and 24 years of age.
CHOC Children's opened an inpatient pediatric mental health unit earlier in 2018. This is the capstone of a comprehensive program with an ambulatory program of graded intensity, including an outpatient day program. The needs for such resources are dire, as at least 20% of children have a mental health challenge in the first 18 years of life. Similar to the rest of the U.S., the inpatient capacity for pediatric mental health in California is minimal and declining, particularly for those less than 13 years of age. As an example, by opening 18 beds in the CHOC Mental Health Inpatient Center (MHIC), the number of such beds in the entire state increased by 20%.
A reliable pediatric mental health system of care has the potential to turn lives around, providing services that reach the children while the developing brain still has the greatest potential to respond. Furthermore, and akin to physical health, treating children early can also have a major effect on the adult mental health crisis.
Commitment Description & Detail:
CHOC Children's, in partnership with committed organizations and community groups, aspires to create an outstanding mental health system of care for all children, teens and young adults in Orange County, CA and surrounding areas. Our goal is to provide a comprehensive approach to pediatric mental illness. Our vision for a mental health system of care recognizes and address the unmistakable link between mental and physical health. Without early identification and treatment, children with early signs are unlikely to escape the long-term impacts on their health and well-being. At CHOC, we believe mental health should be fully integrated with physical health treatment. When needed, the psychology and psychiatry teams work closely with the medical team to attend to patients' emotional, behavioral and developmental needs through inpatient and outpatient therapy.
With this potential for benefit comes risk. The CHOC Children's MHIC was designed with the best current designs for safety and effectiveness of therapy, including novel environments which instill normalcy into daily routines. Most uniquely, parents are even invited partners for the duration of care. But as this PSMF APSS underscores, great care must be taken during all aspects of mental health care delivery. This seriousness of purpose and care delivery is integrated into all aspects of patient care flow and monitoring.
In alignment with the Patient Safety Movement Foundation's Actionable Patient Safety Solutions (APSS) checklist, CHOC Children's Hospital is actively working on our implementation plan. Action Plan:
Executive Plan:
-Provide low barrier ways for staff and patients to collaborate on care planning.
-Promote patients to take more of an active role in identification and management of symptoms.
-Increase patient safety by increasing awareness of and interventions for strong negative emotional states which may precede harm of self or others.
-Be evaluated with metrics such as Client Satisfaction Surveys, patient lengths of stay, patient readmission rates, Code and escalation frequency, and seclusion room use.
Leadership Plan:
• Provide infrastructure. Use an appropriateToolkit to systematically build patient and support skills development in an effective and efficient manner. Collaborative care planning appears to have particularly strong effects in patients with more severe disorders, and even low levels of collaboration can have positive outcomes (Craven et al., 2006). This is particularly important in acute inpatient psychiatry settings, where psychiatric severity tends to be high, and staff often are time and resource constrained (Porter, 1992).
• Provide scope. Develop a guide for staff and physicians to determine appropriate family and supports to be involved in care planning.
• Provide capacity. Protect time to engage in patient comfort planning.
• Provide capability. Educate staff on how to leverage comfort planning, how to engage patients to identify their triggers, and when to seek additional resources.
• Provide motivation. Highlight the importance of patient involvement in patient outcomes, empower staff to take action to proactively assess and include patients in their treatment.
• Provide outcomes. Systematically track and iteratively improve patient engagement by collecting data about outcomes, success rates, adverse events.
Commitment Timeline:
Our commitment to a comprehensive continuum of outpatient and inpatient children's mental and behavioral health will be ongoing and reported to the PSMF APSS on an annual basis.
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APSS #14: Falls & Fall Prevention
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Commitment
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CHOC Children's Hospital
APSS #14: Falls & Fall Prevention
Contact Info
Name: James Cappon
Phone: 17145098590
Email: jcappon@choc.org
Position: Chief Quality Officer
Organization Name: CHOC Children's Hospital
Organization Address:
1201 W. La Veta Ave.
Orange, California 92868 US
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 14 - Falls and Fall Prevention
Commitment Name:
APSS #14: Falls & Fall Prevention
Commitment Start Date:01/01/2015 How Many Hospitals Will This Commitment Represent? 1 Commitment Summary:
Although a more significant problem in hospitalized adults, pediatric patients are also at risk for injury from falls. By far the most common are "developmental falls," in which the child is developing ambulation and self-protection skills appropriate for age and is simultaneously hospitalized or in other health care settings. Less common but generally more potentially serious are falls in ill or injured older children and young adults, similar in etiology to those in older adults. Often this group is characterized by chronic diseases of adolescence with long hospital lengths of stay, perhaps best characterized by oncologic conditions. It is this group that has long been our targeted focus for fall risk detection and injury prevention.
Commitment Description & Detail:
Reducing harm from moderate and severe falls is a Children's Hospitals' Solutions for Patient Safety (CHSPS) HEN network Hospital-Acquired Condition (HAC) being measured and improved. The goal is to have zero moderate or severe harm from preventable falls at CHOC.
Notably, with our risk identification and fall mitigation program in place, there have been zero such falls at CHOC for over 24 months.
In alignment with the Patient Safety Movement Foundation's Actionable Patient Safety Solutions (APSS) checklist, CHOC Children's Hospital has reached our goal and completed our implementation plan around this APSS challenge. Action Plan:
CHOC will continue to implement both PSMF and CHSPS processes around Serious Fall Prevention and will report on an annual basis.
Patient falls are a major cause of in-patient injury and even death. Healthcare administration must develop, revise and support the plan through the following actionable steps: (“Preventing falls in hospitals: a toolkit for improving quality of care.”, 2013; Boushon et al., 2008)
• Assess the existing fall prevention and protection from injury policies, procedures, protocols, and educational programs in relation to current evidence and emerging research.
• Identify existing needs or gaps in the fall prevention and protection from injury policies, procedures, protocols, and knowledge application for employees.
• Identify Opportunities for Improvement and Set Aims (Goodwin et al., 2014; Mion et al., 2012; Mccurley and Pittman, 2014; Waters et al., 2015).
− Collect fall and injury data to assist in advancing precision performance of fall prevention and protection from injury program.
− Debrief all falls, including non-injury falls. Analyze for trends or patterns that assist in advancing performance of the fall prevention and protection from injury strategy.
− Consider bundling evidence-based recommendations to achieve greater outcomes.
− Consider provider training on how to partner with patients and their loved ones on safety strategies to prevent falls and protect from injuries.
− Consider technological advancements to advance performance and reduce injuries.
− Develop a multidisciplinary team to create, implement, and sustain fall prevention and protection from injury initiatives. This team should include, but is not limited to, Executive sponsor, Environmental Manager, Risk Manager, Physical Therapist, Occupational Therapist, Medical Doctor, Unit Manager, frontline nursing staff, or Certified Nursing Assistant. Efforts should be made to get as many representatives from all shifts.
− Develop fall champions throughout all departments who further drive organizational knowledge and action in the healthcare setting.
− Provide clear and concise communication regarding the champion’s role and responsibilities.
− Develop feedback mechanisms to learn what is working and what can be improved upon in the fall prevention and protection from injury plan from the champion’s perspective.
Commitment Timeline:
The CHOC Children's commitment to this APSS will be ongoing and reported annually to the PSMF.
Impact Details
Lives Saved
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APSS #4: Monitoring for Opioid Induced Respiratory Depression
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Commitment
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CHOC Children's Hospital
APSS #4: Monitoring for Opioid Induced Respiratory Depression
Contact Info
Name: James Cappon
Phone: 714-509-8590
Email: jcappon@choc.org
Position: Chief Quality Officer
Organization Name: CHOC Children's Hospital
Organization Address:
1201 W. La Veta Ave.
Orange, California 92868 US
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 4 - Monitoring for Opioid-induced Respiratory Depression
Commitment Name:
APSS #4: Monitoring for Opioid Induced Respiratory Depression
Commitment Start Date:01/01/2016 How Many Hospitals Will This Commitment Represent? 1 Commitment Summary:
Opioid-induced respiratory depression is a leading cause of preventable patient death and serious patient harm events across the medical industry. Hospital leadership must under understand, appreciate and commit to eliminating these events. Implementing an effective program to reduce opioid-induced respiratory depression will require an organized plan which includes both effective monitoring and intervention limbs and also an effort to minimize use of unnecessary narcotics and sedatives. Commitment Description & Detail:
As a tertiary-quaternary regional children's hospital, we have patients of many ages, types and conditions who require use of analgesics for pain, well beyond surgery alone. Thus, the comprehensive use of our Rapid Response Team and Pediatric Early Warning System assessment and monitoring of all non-ICU patients has led to an approximately 85% reduction in non-ICU codes of all types, sustained for nine consecutive years. All such events (N less than 10 per year) are rigorously investigated, including for possible medication-related contributions. There were none of the latter in the last year.
All CHOC patients receiving narcotics are monitored for oxygen saturation at a minimum by policy. Utilizing best practice trigger methodology, all uses of naloxone are investigated for circumstances requiring usage.
In alignment with the Patient Safety Movement Foundation Actionable Patient Safety Solutions (APSS) checklist, CHOC Children's Hospital has completed and reached our goal for the below checklist items.
Action Plan:
-Implement continuous electronic monitoring on all floors where patients are being administered opioids, per hospital policy.
-Monitoring should consist of a minimum SET (Measure Through Motion and Low Perfusion) pulse oximetry with local and central alarms. Direct communication can be sent to bedside personnel versus in-house phone network.
-Respiratory rate alarms are set at age-appropriate, evidence-based parameters to minimize alarm fatigue.
-A rapid response notification system should be in place to alert staff if the patient is deteriorating. A plan for escalation of rapid response alarm to another staff member should also be in place. At CHOC, beginning in mid-2017, a "Watcher Program" for non-ICU patients was established, which identified patients at the earliest stages of deterioration and thus bore "watching." This occurs via a rapid briefing including multidisciplinary clinicians and establishment of a mitigation plan to be achieved within two hours. This is in addition to our PEWS and Rapid Response Team programs, and is meant to achieve even earlier detection of possible deterioration.
-Hospital governance should commit to a plan that includes:
Reviewing all reported preventable patient deaths and serious patient harm events over the previous 24 months where opioids were involved and may have contributed to the preventable event. A review of all previous closed malpractice claims related to opioid-induced respiratory depression should also be undertaken.
-Identifying and prioritizing common contributing factors from those serious preventable events.
-Identifying continuous electronic monitoring technologies that notify staff of significant changes in a patient’s respiratory condition which includes a rapid response approach that ensures appropriate interventions are initiated in a timely manner.
-Providing the resources necessary to implement the chosen plan.
-Continuing to report and assess both near misses and patient harm events for additional learning opportunities and improvement.
-CHOC Children's Hospital has two hospital “champions” who are accountable for successful implementation, education and evaluation of efforts to both minimize the untoward side effects of narcotics and reduce the use of these agents overall. In addition, we are in early stages of joining with another children's hospital in an organized program designed to reduce controlled substance utilization across inpatient and outpatient networks.
• CHOC has a Resuscitation Coordinator RN, who oversees all aspects of the resuscitation program, including, vitally, their prevention by intervening at the earliest signs of deterioration. This role also includes interfacing with local unit leaders to ensure ongoing full compliance with the patient monitoring plan as described above. CHOC also has a longstanding dedicated Pain Nurse Practitioner who coordinates the programmatic efforts at pain prevention and management. In children, extensive multidisciplinary efforts are expended at various forms of distraction therapy. In addition, the benefits of 24/7 parental presence cannot be ignored.
-We are currently working to develop an educational plan for all staff, patients and family members that shares common contributing factors leading to opioid-induced respiratory depression as well as the implementation plan that strives to eliminate current risks associated with opioids.
• Anesthesiology-directed Pain Service
• Pain NP rounds daily
• Orthopedic, Cardiovascular and General Surgery organized protocols to minimize narcotic use Commitment Timeline:
This CHOC Children's program and checklist items are currently in place. Our commitment to this APSS will be ongoing and reported annually to PSMF.
Impact Details
Lives Saved
Methodology for Determining Lives Saved:
The CHOC Non-ICU Code Prevention program, which incorporates all such patients, not just surgical, measures Non-ICU codes per 1000 hospital days. Of the six events last year, none were related to medications or post-operative patients; hence, a rate for this metric of zero. There is no known pediatric benchmark for comparison, so no true way to measure lives saved.
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APSS #5: Anemia and Transfusions
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Commitment
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CHOC Children's Hospital
APSS #5: Anemia and Transfusions
Contact Info
Name: James Cappon
Phone: 714-509-8590
Email: jcappon@choc.org
Position: Chief Quality Officer
Organization Name: CHOC Children's Hospital
Organization Address:
1201 W. La Veta Ave.
Orange, California 92868 US
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 5 - Patient Blood Management
Commitment Name:
APSS #5: Anemia and Transfusions
Commitment Start Date:01/01/2016 How Many Hospitals Will This Commitment Represent? 1 Commitment Summary:
Errors in the use of blood products are a significant cause of hospital patient morbidity and mortality. To eliminate these errors, hospitals must implement an effective Patient Blood Management program. Children are no different in this regard, and given their at times very small size and normal physiologic nadir of hemoglobin in early infancy, are at risk for anemia and related transfusion need, and risks of both the clinical condition and associated treatments. Similarly, children are not immune to potential adverse reactions of transfused products, and all due care must be undertaken.
Commitment Description & Detail:
CHOC continues its comprehensive blood management program this year, which spans the realm of blood collection, pheresis, clinical guidelines to reduce lab testing, practices to reduce laboratory blood test volumes, surgical/procedural practices, transfusion safety, and post-transfusion monitoring. As a tertiary-quaternary regional children's hospital, vulnerable patients are common here, with concomitant transfusion risks and benefits associated with their often chronic conditions.
In alignment with the Patient Safety Movement Foundation's Actionable Patient Safety Solutions (APSS) checklist, CHOC Children's Hospital has completed and reached our goal of using the below checklist items. Our Transfusion Committee has the annual goal of 100% compliance with metrics involving consent and appropriate use of four types of blood products. Our clinical goal is zero adverse events associated with preventable transfusion-related complications, including severe anemia, severe transfusion reactions and Transfusion-Related Acute Lung Injury (TRALI). There were zero such events last year. Action Plan:
-A Commitment from hospital leadership to support a Patient Blood Management program that closes the performance gap by reducing unnecessary transfusions while speeding up needed blood transfusion and care for patients who truly need it.
-Clinical and safety leadership endorse the plan and drive implementation across all providers and systems.
-Establish the Patient Blood Management Committee, which replaces the traditional hospital transfusion committee, and appoint an MD chairperson to be responsible and accountable for leading this group.
• CHOC uses Transfusion, Ancillary and Diagnostics, Operating Room, Patient Safety and Joint Leadership Committees to co-manage related functions
-On a regular basis, distribute the blood product usage report by clinicians across the hospital to hospital leaders.
• Done at CHOC by the Transfusion Committee to individual practitioners. Individual performance is also tracked by the organizational medical staff peer review committee.
-Implement interdisciplinary blood conservation modalities, including:
• Reductions of unnecessary laboratory tests, frequency of blood sampling, and “discard” volumes.
• A consistent protocol for preoperative management of platelet inhibitors and other anticoagulants.
-Technology that has been shown to improve patient care, such as continuous non-invasive hemoglobin monitoring and red cell recovery technology in the operating room (OR).
• CHOC perioperative practice has changed to incorporate regular blood gas sampling that includes hemoglobin. Cell-saving technologies are applied operatively in all appropriate settings, and are a part of many Care Guidelines.
-CHOC is currently working to establish protocols for anemia management, including:
• Screen, diagnose and appropriately treat anemia prior to surgery, allowing adequate lead time to correct the anemia before surgery.
• Identify patients at risk for needing transfusion.
• Increase hemoglobin levels before surgery.
• Minimize the risk of hitting levels that require blood transfusions.
-When appropriate, establish single unit transfusion policy and advocate for restrictive transfusion practices.
-Document hemoglobin levels before the transfusion of each RBC unit, when possible.
-Consider alternative therapies to RBC transfusions, such as intravenous iron or erythropoietin stimulation agents (ESAs).
-Continuously monitor the effectiveness of the Patient Blood Management program, and use the results of this monitoring in medical staff educational sessions as a part of Continuous Quality Improvement (CQI).
-We are currently working to develop a Patient Blood Management education program for emergency and elective hospital admissions, targeting medical students, physicians, nurses, pharmacists and other healthcare staff.
• As an example, the CHOC Electronic Health Record (EHR) CPOE and Decision Support functions provide real time guidance to personnel ordering blood products, particularly for products ordered when evidence-based practice guidelines do not provide clear cut management.
Commitment Timeline:
These checklists items are currently in place at CHOC Children's. Our commitment to this APSS will be ongoing and reported annually to PSMF.
Impact Details
Lives Saved
Methodology for Determining Lives Saved:
The CHOC Children's transfusion medicine program follows all patients, surgical and medical, for transfusion-associated morbidity and mortality. There were zero events of moderate or severe TRALI or hemolytic reactions, and zero mortalities in the last two years.
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APSS #2F: CLABSI
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Commitment
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CHOC Children's Hospital
APSS #2F: CLABSI
Contact Info
Name: James Cappon
Phone: 714-509-8590
Email: jcappon@choc.org
Position: Chief Quality Officer
Organization Name: CHOC Children's Hospital
Organization Address:
1201 W. La Veta Ave.
Orange, California 92868 US
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 2F - Central Line-associated blood stream infections (CLABSI)
Commitment Name:
APSS #2F: CLABSI
Commitment Start Date:07/01/2013 How Many Hospitals Will This Commitment Represent? 1 Commitment Summary:
Central line-associated bloodstream infection (CLABSI) is a potentially severe, even life-threatening complication of medical management of complex care scenarios. It is the most frequent HAC for those children hospitalized in children's hospitals in the U.S., and is also the most costly to treat. It has also proved to be perhaps the most challenging HAC to improve, despite significant efforts.
In order to implement a program to reduce and eliminate CLABSI, CHOC Children's Hospital is actively working on an implementation plan that will require actionable steps. Commitment Description & Detail:
CHOC Children's has been preventing catheter-associated urinary tract infections since well before 2013, when our formal involvement with the Children's Hospitals' Solutions for Patient Safety (CHSPS) began. The CHSPS network is a CMS Pay for Performance Hospital Engagement Network (HEN) of some 130 children's hospitals across the U.S. and Canada, and the only one specific to children's care. The overarching aim is the goal of reducing serious harm in children through the reduction of hospital-acquired conditions (HAC). CHOC uses best practice bundles for central line insertion and maintenance care in an effort to reduce CLABSI.
CLABSI is one of the more frequent HACs, including in children. Despite the focus on central line management best practices (both insertion and maintenance) as well as effective efforts to reduce the duration of time central lines are in place, the incidence has not been dropping as fast as desired. Some of this is due to the types of patients in which central lines are required, i.e., "simple" central line patients have their lines discontinued early. Moreover, it is now known that such catheters are entered multiple times daily. Thus, another avenue for intervention is an active program designed to reduce the number of central line entries each day by "bundling" lab draws, medication administration and IV fluid changes. At CHOC, CLABSI rates are tracked monthly and quarterly, and results distributed broadly across the organization. Tellingly, the "days since last" CLABSI is announced each morning at the CHOC Daily Safety Briefing.
CHOC will continue its efforts at best practice delivery and clinical outcomes in CLABSI prevention for both catheter insertion and ongoing management. In alignment with the Patient Safety Movement Foundation's Actionable Patient Safety Solutions (APSS) checklist, CHOC Children's Hospital has successfully completed and implemented the following checklist items.
Action Plan:
Commitment from hospital leadership to support a program to reduce and eliminate CLABSIs.
Implement evidence-based guidelines to prevent the occurrence of CLABSIs, including: insertion, maintenance, and standardized access procedures.
Doctors and other clinicians should:
• Perform a “time-out”.
• Wash their hands with soap.
• Clean the patient’s skin with chlorhexidine antiseptic.
• Put sterile drapes over the entire patient.
• Wear a sterile mask, hat, gown and gloves.
• Put a sterile dressing over the catheter site.
Develop an education plan for attendings, residents and nurses to cover key curriculum pertaining to the prevention, insertion and maintenance of central lines.
Encourage continuous process improvement through the implementation of quality process measures and metrics.
Standardize a central-line kit based on the needs of your facility, and implement technology that will have a significant return on investment (ROI).
Efforts should be focused on eliminating all blood draws from central access catheters. This includes patient with longer-standing catheters (e.g. dialyses catheters).
• Current organization-wide practice change to reduce central line blood draw frequency
All CLABSIs should have a root cause analysis (RCA) completed by the unit where the infection occurred with multidisciplinary participation including nursing, physicians and infection prevention specialists. All learnings from the RCA should be implemented.
- All CLABSIs at CHOC undergo an Apparent Cause Analysis (ACA) and are discussed in the multidisciplinary Hospital-Acquired Infection team meeting.
CHOC is finding that maintenance care rather than catheter placement is the area of highest risk for the development of CLABSI. Commitment Timeline:
These checklists items are currently in place and our commitment will be ongoing.
Impact Details
Lives Saved
Lives Saved predicted:
0.4994999999999998 For reporting purposes, the number has been rounded up to the nearest whole number. Lives Saved predicted:
1
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APSS #6: Hand-off Communications
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Commitment
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CHOC Children's Hospital
APSS #6: Hand-off Communications
Contact Info
Name: James Cappon
Phone: 714-509-8590
Email: jcappon@choc.org
Position: Chief Quality Officer
Organization Name: CHOC Children's Hospital
Organization Address:
1201 W. La Veta Ave.
Orange, California 92868 US
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 6 - Hand-off Communications
Commitment Name:
APSS #6: Hand-off Communications
Commitment Start Date:01/01/2011 How Many Hospitals Will This Commitment Represent? 1 Commitment Summary:
Accurate and complete hand-off communications (HOC) are vital to patient safety. Modern healthcare practices, particularly inpatient, result in an increased number of potential handoffs. Examples include covering physicians, notably resident physicians due to duty hour restrictions, nursing mandated breaks and required coverage, and increased throughput effectiveness, which can shorten length of time in any given location. When HOC information is incomplete or erroneous, serious patient harm can occur. The establishment of accurate, complete, effective HOC requires an implementation plan, checklists and mindful participation. In some circumstances, families can provide valuable information and clarity; in all cases, lack of communication continuity amongst caregivers is a negative patient experience satisfier. Commitment Description & Detail:
CHOC Children's began formalized work on Handoff Communication in 2011 with participation in a national collaborative of the Children's Hospital Association. In conjunction with some 30 partner children's hospitals, best practices were tested and developed to effectively and accurately communicate essential information in standardized fashion amongst caregivers of multiple types.
This progressed to more recent CHOC activities in this area including electronic, templated bedside shift change handoffs between nurses that include parents. A recent Performance Improvement team concluded its work in that realm, but reducing communication failures which have clinical consequences remains an annual goal of the organization's Patient Safety Committee. Specifically, the Patient Safety Goal is "Reduce Care Failures Due to Handoff Communication." Such events are captured in our electronic Safety Reporting System, and due to safety culture improvements, self-reporting is on the rise.
Our expanding Good Catch program frequently harvests examples of communication failures and rescues amongst its accumulated safety reports.
In alignment with the Patient Safety Movement Foundation's Actionable Patient Safety Solutions (APSS) checklist, CHOC Children's Hospital has completed and reached our goal for utilizing the below checklist items. Action Plan:
-Educate all hospital staff on the following principles and requirements for effective HOC:
-We have identified seventeen different categories of HOC that commonly occur in hospitals or other care units. Each of these categories requires a specific HOC checklist. We have developed the first 6, ready to be implemented:
§ 1b – Emergency Department to Operating Room
§ 2f – Hospital Unit to Home (discharge)
§ 2g – Hospital Unit Shift Change
§ 3b – Operating Room to Hospital Unit
§ 3c – Operating Room to Home
§ 4c – Hospital to Outside Care Unit
In addition, an essential handoff in our organization in from Emergency Department to Inpatient Unit, and Emergency Transport Team to Inpatient Unit.
Commitment Timeline:
CHOC Children's currently has these checklists items are in place. Our commitment to this topic is deep will be ongoing, with annual reporting on this APSS to PSMF.
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APSS #7A: Optimal Neonatal Oxygen Targeting
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Commitment
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CHOC Children's Hospital
APSS #7A: Optimal Neonatal Oxygen Targeting
Contact Info
Name: James Cappon
Phone: 714-509-8590
Email: jcappon@choc.org
Position: Chief Quality Officer
Organization Name: CHOC Children's Hospital
Organization Address:
1201 W. La Veta Ave.
Orange, California 92868 US
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 7A - Optimal Neonatal Oxygen Targeting
Commitment Name:
APSS #7A: Optimal Neonatal Oxygen Targeting
Commitment Start Date:01/01/2013 How Many Hospitals Will This Commitment Represent? 1 Commitment Summary:
Hypoxia in pre-term infants can result in mortality and morbidity. Supplemental oxygen administration helps avoid hypoxia but hyperoxia can cause retinopathy of prematurity (ROP) and increase risk for other conditions including chronic lung disease. Implementing an optimal oxygen targeting strategy can improve neonatal outcomes. For over a decade, CHOC Children's has taken actionable steps to address suboptimal oxygen targeting. The development of a "Small Baby NICU," a freestanding neonatal unit dedicated to the care of Extremely Low Birthweight (ELBW) neonates of less than 28 weeks gestational age or 1000 grams birthweight, has allowed for super-specialized care for these most vulnerable babies. This special, dedicated environment, staff and protocols have furthered the advancement of care for ELBW neonates, and improved outcomes across standard NICU measures, including ROP. Commitment Description & Detail:
CHOC Children's has rigorous neonatal quality improvement plans in place to deliver effective and safe oxygen concentrations to NICU infants. This includes standardized ordering plans and monitoring parameters and associated action steps. CHOC Retinopathy of Prematurity (ROP) rates are historically favorable versus international, national and state benchmarks, including Vermont Oxford Network (VON) and California Perinatal Quality Care Consortium (CPQCC). ROP is also a target of a the Children's Hospitals Neonatal Consortium (CHNC), a group of about 35 children's hospitals Level 4 NICUs, of which CHOC is a member.
As an ongoing goal, CHOC will continue to endeavor to reduce its neonatal ROP annual rate by 10%.
In alignment with the Patient Safety Movement Foundation's Actionable Patient Safety Solutions (APSS) checklist, CHOC Children's Hospital has completed and reached our goal for utilizing the below checklist items. Action Plan:
-Make an organization-wide commitment by administrative, clinical, and patient engagement leaders to address neonatal patient safety related to oxygen administration.
-Assess opportunities to improve oxygen administration and monitoring for the prevention of adverse events due to lack or excess of oxygen.
-Implement interdisciplinary strategies and develop an action plan with a timeline with concrete milestones to implement an optimal oxygen policy for neonates.
-Select technologies that have been shown to improve neonatal outcomes, including but not limited to: blenders, pulse oximetry, and heated humidifiers.
-Determine the oxygen targeting policy that healthcare providers should implement:
¨ The SpO2 for a pre-term baby breathing supplemental oxygen should not exceed 95%.
¨ The SpO2 for other larger infants and neonatal patients should stay in the range of 88-95% or 90-96% depending on infant and condition.
-When the saturation or SpO2 dips below 88%, avoid a response that would induce hyperoxia.
-In order to accomplish this, the oxygen saturation monitor alarms should always be on and active when an infant is breathing supplemental oxygen.
-The high SpO2 alarm should be set to 95%, depending on the infant. The low SpO2 alarm should be set to 85% or as required for special infant circumstances, eg., congenital heart disease.
-Alarms signaling should receive attention from the appropriate bedside clinicians.
-When a baby is not breathing supplemental oxygen, but is being monitored for desaturations, the low SpO2 alarm should in general be set at 85% and the high alarm can be turned off.
-Implement your action plan for including educational activities, workshops, and tools for all members of the neonatal healthcare team.
-Develop a process for continuous improvement by communicating with staff and implementing measures to improve processes in order to meet the oxygen targeting objective. Commitment Timeline:
These checklists items are currently in place at CHOC Children's. Our commitment to this clinical topic and APSS is ongoing and will be reported annually to the PSMF.
Impact Details
Lives Saved
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APSS #15: NG Tube Placement and Verification
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Commitment
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CHOC Children's Hospital
APSS #15: NG Tube Placement and Verification
Contact Info
Name: James Cappon
Phone: 714-509-8590
Email: jcappon@choc.org
Position: Chief Quality Officer
Organization Name: CHOC Children's Hospital
Organization Address:
1201 W. La Veta Ave.
Orange, California 92868 US
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 15 - Nasogastric Tube (NGT) Placement and Verification
Commitment Name:
APSS #15: NG Tube Placement and Verification
Commitment Start Date:07/01/2017 How Many Hospitals Will This Commitment Represent? 1 Commitment Summary:
A nasogastric or NG tube is a plastic tubing device that allows delivery of nutrition directly into the stomach (feeding), or removal of stomach contents (drainage). It is typically passed via the nose and oropharynx into the upper gastrointestinal (GI) tract. Occasionally, these tubes can be malpositioned, leading to significant harm and even death. The most common serious misposition is into the lungs. The National Health Service Improvement (NHSI) in the United Kingdom has placed this type of incident on their “Never Events” list; Never Events are “errors in medical care that are identifiable, preventable, and serious in their consequences for patients, and that indicate a real problem in the safety and credibility of a health care facility” (National Quality Forum). Commitment Description & Detail:
Nasogastric tubes (NGTs) are a commonly used intervention in clinical practice for GI tract decompression or for administration of enteral nutrition, fluids and medications. Misplacement of NGTs can lead to significant morbidity and even death.
CHOC Children's, as a tertiary-quaternary regional children's referral center, supports the care of thousands of fragile children with both acute and chronic, often complex conditions. In many cases, such children are unable to feel orally on their own, yet their gastrointestinal systems are otherwise functional and can receive the optimal form of nutrition. An NGT is thus a frequent adjunct to the acute and occasionally sub-acute care of such children, and when correctly used, can be of great benefit to recovery, growth and outcome. Because of frequent small size, cardiopulmonary, and/or gastrointestinal diseases or conditions, auscultation alone cannot reliably be utilized to confirm NGT placement in these patients.
CHOC has a policy in place to ensure all patients requiring a nasogastric tube are safe throughout the organization. This includes radiographic evidence of NGT location at the time of placement. Action Plan:
• Use only NGTs that are radio-opaque throughout their length with external centimeter length markings to be used to detect post-insertion tube movement.
• Ensure that all staff who place NGTs are specifically trained in this procedure
• Accurately measure the length of the NGT prior to insertion using the NEMU method (Nose→Earlobe→Mid-Umbilicus)
• Confirm NG tube placement with a radiograph per our policy.
• Ensure all staff who read radiographs are specifically trained in reading the radiograph using the following four criteria:
- Does the tube path follow the esophagus and avoid contours of the bronchi?
- Does the tube clearly bisect the carina or the bronchi?
- Does the tube cross the diaphragm in the midline?
- Is the tip clearly visible below the left hemi-diaphragm?
• Document the confirmation of NG tube in the EMR as well as the method of confirmation .
• Secure tubes to the patient after confirmation in such a way that the depth mark is visible at the naris.
• Document this mark in the medical record and used as a point of reference for other caregivers to gauge movement of the tube.
• Observe for signs of respiratory distress or gagging/vomiting and remove tube if these signs are present as NG tube may have been dislodged into the airway or lungs.
• Develop a mandatory reporting system to track nasogastric feeding tube misplacements as a percentage of all tubes placed.
Commitment Timeline:
At CHOC Children's, these checklists items are currently in place. Our commitment to perfect safety in this area is ongoing, and updates to this PSMF APSS will be made annually.
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APSS #1: Creating a Culture of Safety
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Commitment
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CHOC Children's Hospital
APSS #1: Creating a Culture of Safety
Contact Info
Name: James Cappon
Phone: 714-509-8590
Email: jcappon@choc.org
Position: Chief Quality Officer
Organization Name: CHOC Children's Hospital
Organization Address:
1201 W. La Veta Ave.
Orange, California 92868 US
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 1 - Culture of Safety
Commitment Name:
APSS #1: Creating a Culture of Safety
Commitment Start Date:07/01/2011 How Many Hospitals Will This Commitment Represent? 1 Commitment Summary:
Since at least 2000, CHOC Children's Hospital has been steadfastly working to improve the culture of safety within our organization. While this is a continuous journey, not a destination (James Reason, "Managing the Risks of Organizational Accidents;" Ashgate Publishing Ltd; Hants, England, 1997), one measurable output is the Serious Harm Rate, which objectively measures the most severe types of preventable patient harm.
In the mid 2000s, CHOC adopted a quality goal, subsequently an organizational goal in 2011, to Reduce the Serious Harm Rate. It is the highest level measure of the effectiveness of our safety systems and culture to improve the patient safety domain of our organization quality program. Simultaneously, CHOC has been regularly measuring, learning from and responding with action to the validated and widely used Agency for Healthcare Research and Quality (AHRQ) Patient Safety Culture Survey.
Patient Safety simply cannot sustain improvement and performance without a relentless approach to recognizing and modifying organizational safety culture. While discrete safety events can often be prevented through best practice adherence and other campaigns, the fundamental imperatives of just culture, error prevention techniques, human factors engineering and high-reliability can neither be effectively introduced nor maintained without cultural buy in. While this is a journey measured in years, not days, it is one in which patients and their families cannot afford the hesitation of a single step.
Commitment Description & Detail:
CHOC Children's uses the Healthcare Performance Improvement (HPI) Inc. Safety Event Classification (SEC) event classification system to label harm and potential harm events. The CHOC Serious Harm Rate uses the denominator of 1000 inpatient days. Potentially preventable patient harm events are identified from multiple sources, including Daily Safety Briefing, the online Safety Reporting System, morbidity and mortality conferences, and peer review. There are three broad categories within the SEC: Serious Harm, Precursor Safety Event, and Near Miss Event (in order of increasing frequency). The five types of serious harm are: Death, Permanent Severe, Temporary Severe, Permanent Moderate and Temporary Moderate (in order of increasing frequency). All serious safety events undergo detailed analysis, typically root cause level. Analytic efforts then lead to answering the fundamental question of how to improve our systems and culture to prevent recurrence and advance reliability.
Since inception a decade ago, CHOC Children's has reduced its Serious Harm Rate 97.9% to the current 0.05/1000 patient days. While this is a notable improvement, rates alone can be impersonal. For this reason, we also track and discuss the actual number of such children harmed, which can be very impactful, particularly at leadership and lay levels.
In alignment with the Patient Safety Movement Foundation's Actionable Patient Safety Solutions (APSS) checklist, CHOC Children's Hospital is very close to reaching our goal for all of the below checklist items. As the items contain references to "create culture," it is doubtful that such a checklist can - or should - ever be signed off as truly completed.
Action Plan:
Achieving a culture of safety in a healthcare organization requires transformational change which is owned and led by the executive leaders of the organization, including the board, encouraging accountability and transparency. Leadership’s primary goal must be to make their hospital a safe haven for patients.
• Address unexpected outcomes with open disclosure and prompt resolution.
• If patient harm results from a preventable medical error, adopt the CANDOR (Communication and Optimal Resolution) or similar approach: apologize as soon as possible, pay for all care related to the preventable harm, seek a just resolution, and provide ongoing support for patients and families. Clinicians (the “second victims” of patient harm events) may also require attention and support (Lambert et al., 2016).
Create an open and transparent culture that encourages staff to speak up and self-report
Apologize within 60 minutes of discovery
No charge for care related to event
Incentivize lawyers to settle fast
Do event reviews to avoid reoccurrence
Within 30 days of any event review disseminate learning out to the patient, family, hospital system and externally
• Create a standard of care to ensure that clinicians speak with family members to explain what will be changed so this event won’t happen again. Offer family members an opportunity to be involved and witness the change in procedure, etc.
• Create a reliable means to capture and analyze good catches/near-misses. Set a goal that includes aspirations that all errors and incidents are preventable and that zero is the most important goal.
• Implement an electronic adverse event reporting system that allows for both authored and anonymous reporting, tracking, trending and response to aggregate safety data.
• Implement thoughtful and memorable internal branding to keep safety expectations and aligned behaviors top of mind throughout an organization.
Commitment Timeline:
These patient safety culture checklists items are currently in place at CHOC Children's. Our commitment to this APSS will be ongoing and reported yearly.
Impact Details
Lives Saved
Predicted Lives Spared Harm:
0.39999999999999985 For reporting purposes, the number has been rounded up to the nearest whole number. Predicted Lives Spared Harm:
1
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Hospital Español |
Mexico City |
MX |
Hand Hygiene Improvement
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Commitment
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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
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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 - 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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Development of a incident reporting system for notification and analysis of adverse events associated with medical care. – Update – 12.13.18
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Commitment Update
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Hospital Español
Development of a incident reporting system for notification and analysis of adverse events associated with medical care. – Update – 12.13.18
Contact Info
Name: Raquel Martinez Meza
Phone: 0445527555012
Email: raquel.martinez@hespanol.com
Position: Chief Quality Officer
Organization Name: Hospital Español
Commitment Details Commitment Start Date: 01/01/1970 How many hospitals are represented in this commitment?
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 Update:
1. Definition of behaviors of action before an adverse event in the fair culture program
2. Implementation of safety alert bulletins about events that cause severe damage to the patient as an information and learning method for health personnel.
3. Update operational definitions of adverse events in hospital areas
4. "Second victim" program for psychological first aid attention to personnel involved in events that caused harm to the patient.
5. Workshop of notification of adverse events for health personnel about the importance of notification.
Your commitment aligns with APSS
Challenge 1 - 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. Importance of a non-punitive approach.
2. Use of different platforms for the notification of events.
Impact Details
| Initial Commitment |
Commitment Update |
Project Next Year |
Lives Lost
2 |
Lives Lost
2 |
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
3 |
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
3 |
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New Lives Lost (lives lost – actual lives saved)
0 |
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Hospital Español |
Mexico City |
MX |
Prevention of Venous Thromboembolism in Hospitalized Patients
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Commitment
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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 - 12.20.18
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Commitment Update
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Hospital Español
Prevention of Venous Thromboembolism in Hospitalized Patients – Update – 12.20.18
Contact Info
Name: Raquel Martinez Meza
Phone: 0445527555012
Email: raquel.martinez@hespanol.com
Position: Chief Quality Officer
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 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 Update:
1. The thromboprophylaxis committee has been the same during the year in which the evaluation and management processes of patients with risk of thrombosis are reviewed and the characteristics of internal medicine, critical medicine, vascular surgery, general surgery and orthopedics are integrated.
2. Involvement of specialty physicians: internal medicine, orthopedics and vascular surgery to strengthen the communication process with treating physicians to make decisions about the management and follow-up of patients.
3. Reinforcement in the process of revaluation of hospitalized patients by undergraduate internal doctors
4. Use of the electronic clinical file for the control and monitoring of hospitalized patients.
5. Improvement of education strategies focused on the patient and family on venous thromboembolic disease
Your commitment aligns with APSS
Challenge 12A - Venous Thromboembolism (VTE) Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
Evaluation of risk of venous thromboembolic disease to all hospitalized patients
Incorporate the thromboprophylaxis section during shift change to improve the communication of patients at risk among health personnel
Impact Details
| Initial Commitment |
Commitment Update |
Project Next Year |
Lives Lost
6 |
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
42 |
Lives Spared Harm Target for following calendar year
11 |
Lives Saved Target
0 |
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
2 |
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New Lives Lost (lives lost – actual lives saved)
0 |
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Hospital Español |
Mexico City |
MX |
Improving the Safety of Airway Management
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Commitment
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Hospital Español
Improving the Safety of Airway Management
Contact Info
Name: Raquel Martinez Meza
Phone: 0445527555012
Email: raquel.martinez@hespanol.com
Position: Chief Quality Officer
Organization Name: Hospital Español
Organization Address:
Av Ejército Nacional 613, Granada
Mexico City, Mexico City 11520 MX
Participants:
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Dr. Ricardo Martinez Zubieta, Chief Medical Officer
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Dr. Luis Torres Torija, Quality and Patient Safety Coordinator
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 8A - Safer Airway Management
Commitment Name:
Improving the Safety of Airway Management
How Many Hospitals Will This Commitment Represent? 1 Commitment Summary:
There are patients who need a functional airway to maintain their respiratory and ventilatory needs so mishandling this can result in various complications that can worsen the patient's situation even putting their lives at risk. Commitment Description & Detail:
The management of the airway is one of the fundamental elements in the patient care, so the strategies implemented by the Hospital Español aim to ensure adequate ventilation as well as avoiding complications, this being a priority in various groups of patients such as critical patients. Action Plan:
1. Evidence-based bundles for safer advanced airway management.
2. Specific care protocols for the management of safe airways in emergency situations, as well as patients who are in the Intensive Care Unit, emergency, hospitalization and surgical departments.
3. Support process with anesthesiologists for difficult airway management throughout the hospital.
4. Intubation equipment for difficult airway present in areas considered critical for the hospital such as emergency, intensive care unit and coronary care departments.
5. Report of adverse events related to airway management such as: multiple attempts, dental injury or esophageal intubation.
Commitment Timeline:
The timeline for improving the safety of airway management will be from November 21, 2018 – November 21, 2019
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Hospital Español |
Mexico City |
MX |
Fall Risk Prevention in Hospitalized Patients
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Commitment
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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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Fall Risk Prevention in Hospitalized Patients - Update - 12.14.18
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Commitment Update
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Hospital Español
Fall Risk Prevention in Hospitalized Patients – Update – 12.14.18
Contact Info
Name: Raquel Martinez Meza
Phone: 0445527555012
Email: raquel.martinez@hespanol.com
Position: Chief Quality Officer
Organization Name: Hospital Español
Commitment Details Commitment Start Date: 07/02/2018 How many hospitals are represented in this commitment?
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 Update:
1. Use of medication list that serves as support for a better understanding in health personnel of the effects that could condition an increased risk of falls for the patient.
2. Integrate list of high-risk patients for reception staff that allows greater communication and control of patients with the nursing staff.
3. Standardization of the risk assessment tool for falls in the area of adult and pediatric hospitalization.
4. Improve the education program directed to patient-family using electronic platforms.
5. Implementation of visual alerts such as blackboard in rooms where the risk of falls is recorded and updated, use of specific identifiers for high-risk patients at the door of the rooms.
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 importance of analyze all the falls to identify areas of opportunity in the organization.
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
9 |
Lives Spared Harm Target for following calendar year
7 |
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
0 |
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New Lives Lost (lives lost – actual lives saved)
0 |
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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 |
Preventing Central Line Associated Bloodstream Infection (CLABSI)
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Commitment
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Hospital Español
Preventing Central Line Associated Bloodstream Infection (CLABSI)
Contact Info
Name: Raquel Martinez Meza
Phone: 0445527555012
Email: raquel.martinez@hespanol.com
Position: Chief Quality Officer
Organization Name: Hospital Español
Organization Address:
Av Ejército Nacional 613, 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 and Patient Safety Coordinator
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 2F - Central Line-associated blood stream infections (CLABSI)
Commitment Name:
Preventing Central Line Associated Bloodstream Infection (CLABSI)
How Many Hospitals Will This Commitment Represent? 1 Commitment Summary:
Central line-associated bloodstream infection (CLABSI) is a life-threatening and preventable complication. The most important action that can be done is good hand hygiene and the use of insertion and maintenance methods.
CLABSIs lead to prolongation of hospital stay and increase in health care cost and mortality. An estimated 250,000 blood stream infections occur annually, and most are related to the presence of intravascular devices, resulting in thousands of deaths each year and billions of dollars in added costs to the healthcare system, yet these infections are preventable.
Commitment Description & Detail:
Define strategies based on the best evidence to prevent the risk of CLABSI involving multidisciplinary teams, care bundles, education programs and patient monitoring to minimize the risk of infection. Action Plan:
1. Evidence-based bundles for central catheter installation and management
2. Definition of responsibilities where the installation of the central line is only performed by doctors of vascular surgery and intensive care.
3. Standardization of the center line insertion kit.
4. Nursing education every 2 months based on the best practices of care of the central and peripherals lines.
5. Feedback to the nursing staff by the Epidemiological Surveillance Unit of the Hospital (UVEH) on manipulation of vascular accesses.
6. Taking and monitoring blood cultures in patients with suspected infection.
7. Daily visits to patients with a central line by the staff of the UVEH for review (placement, cleaning, adhesion), healing and verification of vascular accesses.
8. Practical skills competency assessments for family members and caregivers of patients with central catheter that leave the hospital to ensure proper handling of the central line.
9. Periodic audits with report of results to the areas and services of the hospital.
10. Analysis of the results of the audits in the Infection Control Committee.
Commitment Timeline:
The timeline for reducing CLABSI rate will be from November 13, 2018 – November 13, 2019
Impact Details
Lives Saved
Lives Saved predicted:
0.007399999999999986 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 |
Optimize Oxygen Supply for Neonates
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Commitment
×
Hospital Español
Optimize Oxygen Supply for Neonates
Contact Info
Name: Raquel Martinez Meza
Phone: 0445527555012
Email: raquel.martinez@hespanol.com
Position: Chief Quality Officer
Organization Name: Hospital Español
Organization Address:
Av Ejército Nacional 613, Granada
Mexico City, Mexico City 11520 MX
Participants:
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Dr. José Iglesias Leboreiro, Pediatrician-in-Chief
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Dr. Luis Torres Torija, Quality and Patient Safety Coordinator
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 7A - Optimal Neonatal Oxygen Targeting
Commitment Name:
Optimize Oxygen Supply for Neonates
How Many Hospitals Will This Commitment Represent? 1 Commitment Summary:
Oxygen therapy is one of the most important care that is performed in a neonatal unit, where the prevention of retinopathy of prematurity continues to be a major challenge. Oxygen is a medicinal gas with significant side effects where prolonged use can cause injuries. Commitment Description & Detail:
In the Hospital Español strategies have been developed for the correct administration and monitoring of oxygen in premature or underweight infants where its toxicity at this stage of life is very high. Action Plan:
1. Protocols for optimizing the use of oxygen, including setting the alarm for newborns.
2. Policy on the management of supplementary oxygen that includes the definition of the intervals of oxygen saturation levels acceptable to the organization (90-95%).
3. Training program and educational sessions directed to health personnel on the management of oxygen in premature or low birthweight infants.
4. Monitoring of oxygen saturation by health personnel 24 hours a day.
5. Use of oxygen mixers and humidifiers in all areas of pediatrics and delivery rooms for cases where necessary.
6. Ophthalmological examination in all newborns in the neonatal intensive care unit.
Commitment Timeline:
The timeline for optimize oxygen supply will be from November 13, 2018 – November 13, 2019
Impact Details
Lives Saved
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Hospital Español |
Mexico City |
MX |
Detection of Critical Congenital Heart Disease (CCHD) in Newborns
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Commitment
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Hospital Español
Detection of Critical Congenital Heart Disease (CCHD) in Newborns
Contact Info
Name: Raquel Martinez Meza
Phone: 0445527555012
Email: raquel.martinez@hespanol.com
Position: Chief Quality Officer
Organization Name: Hospital Español
Organization Address:
Av Ejército Nacional 613, Granada
Mexico City, Mexico City 11520 MX
Participants:
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Dr. José Iglesias Leboreiro, Pediatrician-in-Chief
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Dr. Luis Torres Torija, Quality and Patient Safety Coordinator
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 7B - Failure to detect Critical Congenital Heart Disease (CCHD) in newborns
Commitment Name:
Detection of Critical Congenital Heart Disease (CCHD) in Newborns
How Many Hospitals Will This Commitment Represent? 1 Commitment Summary:
In Mexico, congenital heart diseases are the second cause of death in the first year of life, where children with heart disease are often diagnosed by physical examination findings of heart murmurs, tachypnea or cyanosis while in nurseries, however these manifestations are usually become evident after leaving the hospital where they can quickly decompensate. Commitment Description & Detail:
The Hospital Español has developed strategies to ensure the comprehensive care of newborns for the early diagnosis of congenital heart diseases that can have significant morbidity. Action Plan:
1. Cardiological screening protocol by monitoring the pulsation in the preductal and postductal circulation in newborns at 24-48 hours of life or just before discharge.
2. Use of echocardiography as a diagnostic aid in all patients who have undergone cardiac screening to confirm normal anatomy.
3. Follow-up of patients with positive screening by the pediatric cardiologist of the institution for immediate consultation.
4. Education plan for health personnel on aspects related to congenital heart disease and the importance of cardiological screening in newborns.
5. Education to relatives of the patient on the importance of cardiological screening.
6. Quality indicators on the cardiological screening process
Commitment Timeline:
The timeline for reducing the ventilator associated pneumonia will be from November 13,2018 – November 13, 2019
Impact Details
Lives Saved
Lives Saved predicted:
4.289999999999999 For reporting purposes, the number has been rounded up to the nearest whole number. Lives Saved predicted:
5
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Hospital Español |
Mexico City |
MX |
Reducing Pediatric Adverse Drug Events
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Commitment
×
Hospital Español
Reducing Pediatric Adverse Drug Events
Contact Info
Name: Raquel Martinez Meza
Phone: 0445527555012
Email: raquel.martinez@hespanol.com
Position: Chief Quality Officer
Organization Name: Hospital Español
Organization Address:
Av Ejército Nacional 613, Granada
Mexico City, Mexico City 11520 MX
Participants:
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José Iglesias Leboreiro, Pediatrician-in-Chief
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Dr. Luis Torres Torija Arguelles, Quality and Patient Safety Coordinator
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 3D - Pediatric Adverse Drug Events
Commitment Name:
Reducing Pediatric Adverse Drug Events
How Many Hospitals Will This Commitment Represent? 1 Commitment Summary:
Medication errors are one of the main causes of adverse events throughout the world, where the pediatric population becomes a highly vulnerable group since the presentation of medications in pediatric doses is limited, in addition to the physiological characteristics in each group of pediatric patients (age and weight). Commitment Description & Detail:
The Hospital Español continues working on the implementation of more effective safety barriers and providing tools to health personnel for the prevention of adverse events that put at risk a vulnerable population such as pediatric patients. Action Plan:
1. Maintain a system for managing and using medicines in a multidisciplinary, comprehensive and systematic manner with a focus on patient safety.
2. Develop and strengthen knowledge in the use of medicines and the skills for the application of good practices in order to improve the safety in their use.
3. Use of barcode equipment for the identification of medications in the administration process.
4. Reporting system for adverse events related to medication incidents for analysis, identification of patterns and trends and performance improvements.
5. System of dose verification in the administration of medicines for newborns and pediatric patients.
6. Management of drug infusion pumps that include concentrations related to the patient's weight.
7. Safety alerts for high-risk medications.
8. Support for health personnel through consultation tools for the evaluation, selection, dosage and therapeutic use of medicines.
Commitment Timeline:
The timeline for Reducing Pediatric Adverse Drug Events will be from November 13, 2018 – November 13, 2019
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Hospital Español |
Mexico City |
MX |
Reduction of Unplanned Extubations
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Commitment
×
Hospital Español
Reduction of Unplanned Extubations
Contact Info
Name: Raquel Martinez Meza
Phone: 0445527555012
Email: raquel.martinez@hespanol.com
Position: Chief Quality Officer
Organization Name: Hospital Español
Organization Address:
Av Ejército Nacional 613, Granada
Mexico City, Mexico City 11520 MX
Participants:
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Ricardo Martinez Zubieta, Chief Medical Officer
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Dr. Luis Torres Torija, Quality and Patient Safety Coordinator
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 8B - Unplanned Extubation
Commitment Name:
Reduction of Unplanned Extubations
How Many Hospitals Will This Commitment Represent? 1 Commitment Summary:
Unplanned extubation is a frequent event that can lead to cardiorespiratory arrest and is associated with respiratory tract injuries, laryngeal and tracheal edema, difficult reintubation, need for cricothyrotomy and increased risk of nosocomial infections, morbidity and mortality. Commitment Description & Detail:
The strategies of the Hospital Español to reduce the incidence of unplanned extubations have shown that, through staff training, the identification of patients at risk and the development of sedation and analgesia protocols, as well as the withdrawal as soon as possible from mechanical ventilation it is viable to decrease the incidence of unplanned extubations. Action Plan:
1. Sedation and analgesia protocols of patients admitted to the intensive care unit.
2. Protocol of care for the management of intubated patients that includes clinical evaluation and capnography to determine the correct ventilation of the patient and adequate position of the endotracheal tube.
3. Evidence- based bundle for the management of intubated patients in the intensive care unit.
4. Report all unplanned extubation incidents and complications, as well as use of quality metrics related to the number of extubations in the intensive care unit.
5. Notification in the adverse events system about any unplanned extubation that occurs and monitoring of all possible complications in these patients.
Commitment Timeline:
The timeline for reducing unplanned extubations in patients will be from November 13, 2018 – October 13, 2019
Impact Details
Lives Saved
Lives Saved predicted:
0.378 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 |
Quality and Patient Safety Program for academic / assistance staff
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Commitment
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Hospital Español
Quality and Patient Safety Program for academic / assistance staff
Contact Info
Name: Raquel Martinez Meza
Phone: 0445527555012
Email: raquel.martinez@hespanol.com
Position: Chief Quality Officer
Organization Name: Hospital Español
Organization Address:
Av Ejército Nacional 613, Granada
Mexico City, Mexico City 11520 MX
Participants:
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Dr. Rafael Puppo Castro, Quality and Patient Safety Coordinator
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Dr. Luis Torres Torija, Quality and Patient Safety Coordinator
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 17 - Patient Safety Curriculum
Commitment Name:
Quality and Patient Safety Program for academic / assistance staff
How Many Hospitals Will This Commitment Represent? 1 Commitment Summary:
It is estimated that 1 in 10 patients treated at the hospital will suffer an adverse event during their care, where 50% of these events were preventable in some way. In health institutions, advances in patient safety have been slow, partly hampered by undeveloped competencies of health personnel, as well as health systems whose main priority is not patient safety. Commitment Description & Detail:
The Hospital understands the importance of patient safety and teamwork with a systemic approach as a priority in the care provided, which is why strategies have been developed to train staff skills to reduce the presence of adverse events in the organization. Action Plan:
1. The course of Patient Safety is taught as part of the academic program to all the medical interns in order to provide a general view on patient safety and its implications in the hospital context with topics such as communication, learning from the error and leadership.
2. Workshop on patient safety for resident doctors on an annual basis, where first-year residents perform a virtual diploma on patient safety.
3. Virtual diploma on patient safety focused on clinical staff (nursing service) and medical leaders of the organization with the intention of developing competencies necessary to improve the quality and patient safety.
4. Introduction in the Nursing Degree of the Hospital school the course of quality and patient safety with the objective that when the students graduate , they can be incorporated to the staff of the hospital with knowledge related to patient safety.
Commitment Timeline:
The timeline for improving the knowledge and competencies related to patient safety will be from November 13, 2018 – November 13, 2019
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Hospital Español |
Mexico City |
MX |
Improving Hand-off Communications
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Commitment
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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 (pedVAP/PVAP)
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 |
Improving the safeguarding and use of medications
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Commitment
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Hospital Español
Improving the safeguarding and use of medications
Contact Info
Name: Raquel Martinez Meza
Phone: 0445527555012
Email: raquel.martinez@hespanol.com
Position: Chief Quality Officer
Organization Name: Hospital Español
Organization Address:
Av Ejército Nacional 613, Granada
Mexico City, Mexico City 11520 MX
Participants:
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Lic. Mayka Janeiro Leboreiro, Administrative director
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 3E - Standardize and Safeguard Medicine Administration
Commitment Name:
Improving the safeguarding and use of medications
How Many Hospitals Will This Commitment Represent? 1 Commitment Summary:
Medication errors and their negative consequences continue to constitute a serious public health problem, not only because of the repercussions already known from the human, welfare and economic point of view, but also because the distrust of patients in the system harms the health professionals and health care institutions. Commitment Description & Detail:
Manage the acquisition and distribution of medications , through administrative processes that allow inventory management and control that reduces costs and promotes the correct flow of them and also meets the needs of the medical staff to provide safe and quality care to our patients. Action Plan:
1. Maintain a system for managing and using medicines in a multidisciplinary, comprehensive and systematic manner with a focus on patient safety.
2. Use of universal checklists for the administration of medicines.
3. Change of format of medical indications to electronic record to improve drug control.
4. Use of barcode equipment for the identification of medications in the administration process.
5. Safety alerts for high-risk and high-cost medications.
6. Systemic response strategy for the case of acute medication shortages.
7. Indicators for the management and control of medication.
Commitment Timeline:
The timeline for improving the safeguarding and use of medications will be from November 8, 2018 – November 8, 2019
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Hospital Español |
Mexico City |
MX |
Reducing the Risk of Medication Errors
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Commitment
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Hospital Español
Reducing the Risk of Medication Errors
Contact Info
Name: Raquel Martinez Meza
Phone: 0445527555012
Email: raquel.martinez@hespanol.com
Position: Chief Quality Officer
Organization Name: Hospital Español
Organization Address:
Av Ejército Nacional 613, Granada
Mexico City, Mexico City 11520 MX
Participants:
-
Lic. Mayka Janeiro Leboreiro, Administrative Director
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 3A - Medication Errors
Commitment Name:
Reducing the Risk of Medication Errors
How Many Hospitals Will This Commitment Represent? 1 Commitment Summary:
Patient safety has become a priority worldwide and medication errors account for a significant percentage of preventable adverse effects. Commitment Description & Detail:
One of the main objectives of the Hospital Español is to identify more effective safety barriers and defenses to prevent the incidence of risk in the use of medicines and / or mitigate the consequences; implementing good practices (political, administrative and assistance). Action Plan:
1. Maintain a system for managing and using medications in a multidisciplinary, comprehensive and systematic manner with a focus on patient safety.
2. Automation of the medication system to reduce risks.
3. Safety alerts for high-risk medications.
4. Implementation of a preparation room to obtain greater control and quality on the preparation and dispensation of sterile mixtures: nutritional and medicinal.
5. Use of barcode equipment for the identification of medications in the administration process.
6. Develop and strengthen knowledge in the use of medicines and the skills for the application of safe practices in responsible health personnel, in order to improve safety in their use.
7. Application of the correct medication and identification strategies for high-risk medications and LASA.
8. Indicators for the management of medications in all the hospital services.
9. Analysis of the results of the audits in the Pharmacovigilance Committee.
Commitment Timeline:
The timeline for reducing medication errors will be from November 9, 2018 – November 9, 2019
Impact Details
Lives Saved
Lives Saved predicted:
0.28200000000000025 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 and Resuscitation of In-hospital Cardiac Arrest
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Commitment
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Hospital Español
Prevention and Resuscitation of In-hospital Cardiac Arrest
Contact Info
Name: Raquel Martinez Meza
Phone: 0445527555012
Email: raquel.martinez@hespanol.com
Position: Directora de calidad
Organization Name: Hospital Español
Organization Address:
Av Ejército Nacional 613, Granada
Mexico City, Mexico City 11520 MX
Participants:
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Dra. Santa López Márquez, Critical Care Physician
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Dr. Luis Torres Torija, Quality and Patient Safety Coordinator
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 10 - Systematic Prevention and Resuscitation of In-hospital Cardiac Arrest
Commitment Name:
Prevention and Resuscitation of In-hospital Cardiac Arrest
How Many Hospitals Will This Commitment Represent? 1 Commitment Summary:
Cardiac arrest is one of the leading causes of death in our country, being the third cause of death after cancer and heart disease. Survival of patients suffering from cardiorespiratory arrest within a hospital depends on factors associated with the type of patient and the response organization system. Therefore, it is likely to increase survival through health education assistance. Commitment Description & Detail:
The time between the start of the cardiac arrest and the provision of care is essential, and shortening this time is one of the best ways to reduce the risk of death and disability due to cardiac arrest, so the organization will establish strategies to guide the provision of services in a timely and safe way. Action Plan:
1. Institutional protocol for the management of patients requiring cardiopulmonary resuscitation. (CPR).
2. Educational program for the management of patients requiring cardiopulmonary resuscitation.
3. Hospital multidisciplinary CPR Committee to review reports of submitted codes, response times, staff training reports and supplies related to CPR aspects.
4. Care planning included in the blue code protection protocol.
5. Educational training for medical and nursing staff in Advanced Cardiopulmonary Resuscitation (ACLS) and Advanced Vital Cardiac Support in Pediatrics (PALS) emphasizing the staff of critical areas.
6. Basic first aid training for non-clinical staff in the course of Heart Guards with Automated External Defibrillator (AED).
7. Installation of automated external defibrillator equipments in non-clinical areas of the hospital.
8. Periodic drills in different areas and shifts of the hospital where personnel of the organization are involved.
9. Implementation of rapid response teams that allow a rapid and effective assistance response to cardiac arrest according to the best evidence.
Commitment Timeline:
The timeline for improving the Prevention and Resuscitation of In-hospital Cardiac Arrest will be from November 9, 2018 – November 9, 2019
Impact Details
Lives Saved
Predicted Lives Spared Harm:
0.4500000000000002 For reporting purposes, the number has been rounded up to the nearest whole number. Predicted Lives Spared Harm:
1
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Dignity Health |
CA |
US |
Antimicrobial Stewardship
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Commitment
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Dignity Health
Antimicrobial Stewardship
Contact Info
Name: Candace Fong
Phone: 9168389236
Email: candace.fong@dignityhealth.org
Position: System Director of Pharmacy and Medication Safety
Organization Name: Dignity Health
Organization Address:
3400 Data Dr
Rancho Cordova, CA 95670 US
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 3B - Antimicrobial Stewardship
Commitment Name:
Antimicrobial Stewardship
How Many Hospitals Will This Commitment Represent? 38 Commitment Summary:
Antimicrobial use has been noted to be over prescribed and has led to increased resistance and unwarranted patient exposure to side effects. The CDC and WHO have vast efforts in reducing the inappropriate use of antimicrobials and our efforts align with these agencies. Commitment Description & Detail:
Dignity Health as established a system approach to support antimicrobial stewardship. We have developed a system steering committee to lead the efforts to reduce the over use of antimicrobials that include leadership support, standardization in the EHR, standard protocols, and a strategic plan to continue a system focus. Action Plan:
• System P & T support
• System White Paper
• Restrictions for fluoroquinolones – quality metric
• Required indications
• 48hr time out
• Therapeutic interchanges
• IV to PO interchange
• System Database to track Days of Therapy
• Quarterly monitoring for adherence to CDC Core Elements
• NHSN AU/ AR data submission
Commitment Timeline:
These strategies will be completed and new efforts started....this will be an on -going process
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Dignity Health |
CA |
US |
Improving the Prevention of Severe Hypoglycemia
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Commitment
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Dignity Health
Improving the Prevention of Severe Hypoglycemia
Contact Info
Name: Candace Fong
Phone: 9168389236
Email: candace.fong@dignityhealth.org
Position: System Director of Pharmacy and Medication Safety
Organization Name: Dignity Health
Organization Address:
3400 Data Dr
Rancho Cordova, CA 95670 US
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 3C - Severe Hypoglycemia
Commitment Name:
Improving the Prevention of Severe Hypoglycemia
How Many Hospitals Will This Commitment Represent? 38 Commitment Summary:
Severe hypoglycemia can be life threatening and often is associated with increased morbidity, mortality and length of stay in the hospital. The inappropriate management of blood glucose in the hospital can result in severe hypoglycemia and is often avoidable. Commitment Description & Detail:
Dignity Health has focused on reducing severe hypoglycemia for the past five years. The approach has been, amongst many efforts, a full scale education to the standardized basal bolus order sets as well mealtime coordination of insulin. Practice variations have been identified that have contributed to low blood glucose. Those variations were addressed at facility levels but shared on monthly calls that focus on the management of blood glucose. The use of toolkits and frequent data sharing has also facilitated our improvement Action Plan:
• Standardized Basal Bolus order set
• Standard approach to meal time coordination of insulin
• Education to all clinicians
• Standard Hypoglycemia protocol
• Monthly submission of results
• Monthly analysis of all outliers
• Monthly webinar with current results
• Monthly discussion of best practices
• Glycemicare Module integrated into the EHR
• Monthly upload to eQUIPs and analysis of aggregate data Commitment Timeline:
This is an on going focus for our organization
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Dignity Health |
CA |
US |
Elimination of CLABSI
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Commitment
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Dignity Health
Elimination of CLABSI
Contact Info
Name: Roy Boukidjian
Phone: 818-921-0380
Email: Roy.Boukidjian@DignityHealth.org
Position: System Director, Infection Prevention
Organization Name: Dignity Health
Organization Address:
185 Berry st , Suite 300
San Francisco, CA 94107 US
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 2F - Central Line-associated blood stream infections (CLABSI)
Commitment Name:
Elimination of CLABSI
Commitment Start Date:12/14/2018 How Many Hospitals Will This Commitment Represent? 39 Commitment Summary:
Central Line Associated Blood Stream Infections (CLABSI) are serious infections typically causing an increased length of stay and increased cost. In addition, it is estimated that CLABSI accounts for an average mortality rate of 18% . Central lines are seen as a medical necessity but also as a device that provides convenience to healthcare providers and patients on occasion. Given this reality, over utilization of central lines are well documented in literature as well as inappropriate collection technique of blood cultures drawn from these lines which eventually leads to inappropriate antibiotic administration and potential bacterial resistance formation. Commitment Description & Detail:
Dignity Health plans to address CLABSIs by standardizing policies and protocols across the organization to ensure appropriate selection, maintenance, and removal is done consistently across all hospital settings. In addition, work with internal and external partners (e.g., supply chain, contracted dialysis companies) to ensure product selection and external policies and procedures align with current evidenced based practice. Action Plan:
Dignity Health will take the following steps:
- Standardize vascular access policies across all facilities
- Establish uniform education across the organization on proper insertion, maintenance, and discontinuation of lines
- Implement technology across the system to reduce false positive blood cultures in collaboration with laboratory leadership
- Work with hospitalist to critically review line necessity on a daily basis
Commitment Timeline:
12 months from start date
Impact Details
Lives Saved
Lives Saved predicted:
3.85725 For reporting purposes, the number has been rounded up to the nearest whole number. Lives Saved predicted:
4
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Dignity Health |
CA |
US |
Eliminating C-diff Infections
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Commitment
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Dignity Health
Eliminating C-diff Infections
Contact Info
Name: Roy Boukidjian
Phone: 818-921-0380
Email: Roy.Boukidjian@DignityHealth.org
Position: System Director, Infection Prevention
Organization Name: Dignity Health
Organization Address:
185 Berry st , Suite 300
San Francisco, CA 94107 US
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 2E - Clostridium difficile infection (CDI)
Commitment Name:
Eliminating C-diff Infections
Commitment Start Date:12/14/2018 How Many Hospitals Will This Commitment Represent? 39 Commitment Summary:
Clostridium difficile (C-diff) has emerged as one of the most significant healthcare-associated infection in recent years surpassing central line associated blood stream infections (CLABSI), catheter associated urinary tract infections (CAUTI), and surgical site infections (SSI). C-diff can survive on surfaces for extended periods of time and is commonly triggered by overuse of antibiotics outside the healthcare setting and within. Historically Dignity Health has struggled to reduce C-diff events given the multiple discipline involvement that is required to curb infection (e.g., Lab, Pharmacy, Physicians, Infection Prevention, EVS, Nursing). Commitment Description & Detail:
Dignity Health will create multiple system strategies in collaboration with the multi-disciplinary team to address all facets of C-diff prevention Action Plan:
Dignity Health will take the following actions:
- Create a gap analysis of evidence based practice and require facilities to complete within 30 days
- Produce a checklist of evidence based practice to eliminate C-diff infection for local facility adoption
- Educate nursing staff on clinical presentation of C-diff for early detection and isolation
- Standardized laboratory method of testing to limit false positives across the organization
- Require all C-diff cases to be reviewed by the local antimicrobial stewardship team
- Implement electronic health record clinical decision support for physicians in order to prevent false positives and unnecessary antibiotic administration
- Standardized quality assurance testing for environmental services across all facilities
Commitment Timeline:
12 months from start date
Impact Details
Lives Saved
Lives Saved predicted:
6.156000000000003 For reporting purposes, the number has been rounded up to the nearest whole number. Lives Saved predicted:
7
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Dignity Health |
CA |
US |
100% System-wide Adoption of Person and Family Engagement
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Commitment
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Dignity Health
100% System-wide Adoption of Person and Family Engagement
Contact Info
Name: Priscilla Vierra
Phone: 415-438-5641
Email: priscilla.vierra@dignityhealth.org
Position: Director, Patient Safety & Clinical Risk Support
Organization Name: Dignity Health
Organization Address:
185 Berry Street , Ste. 300, Lobby 2
San Francisco, CA 94107 US
Participants:
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Barbara Pelletreau, Senior Vice President, Patient Safety
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 16 - Person and Family Engagement
Commitment Name:
100% System-wide Adoption of Person and Family Engagement
How Many Hospitals Will This Commitment Represent? 36 Commitment Summary:
Dignity Health is committing to 100% adoption of each of the 5 person and family engagement (PFE) metrics. By this commitment, Dignity Health aims to fully engaging patients and their families and partnering with them to make improvements to all aspects of care.
Commitment Description & Detail:
Dignity Health will track and measure the adoption of the 5 PFE metrics by: 1. PFE 1 - Preadmission Planning Checklist: confirm the hospital has a physical planning checklist that is discussed with every patient who has a scheduled admission 2. PFE 2 - Shift Change Huddles OR Bedside Reporting: confirm the hospital conducts shift change huddles or bedside reporting with patients and family members in all feasible cases 3. PFE 3 - Designated PFE Leader: confirm the hospital has a designated individual(s) with leadership responsibility and accountability for PFE 4. PFE 4 - PFAC or Representatives on Hospital Committee: confirm the hospital has an active Patient and Family Advisory Council (PFAC) or at least one patient who serves on a patient safety or quality improvement committee or team 5. PFE 5 - Patient Representative(s) on the Board of Directors: confirm the hospital has one or more patient(s) who serve on a governing and/or leadership board as a patient representative Action Plan:
Dignity Health will do the following to support 100% adoption: 1. Distribute the PFE Strategic Vision Roadmap 2. Collaborate with the following hospital leaders for adoption: CNEOs, Surgery Directors, Patient Safety Officers, Quality Directors and Patient Experience Leads 3. Conduct hospital surveys to track and measure adoption Commitment Timeline:
December 2019
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Dignity Health |
CA |
US |
Fall Prevention Program
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Commitment
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Dignity Health
Fall Prevention Program
Contact Info
Name: Margaret Swisher
Phone: (805) 482-1239
Email: margaret.swisher@dignityhealth.org
Position: Director, Regulatory Readiness
Organization Name: Dignity Health
Organization Address:
185 Berry St. Suiite 300
San Francisco, CA 94107 US
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 14 - Falls and Fall Prevention
Commitment Name:
Fall Prevention Program
How Many Hospitals Will This Commitment Represent? 37 Commitment Summary:
Fall Reduction and Prevention Program Commitment Description & Detail:
Dignity Health has committed to a standardized Fall Reduction and Prevention Program. The Dignity Health Fall Team is interdisciplinary including system and facility leaders in nursing, therapy, patient safety, quality, IT, informatics, supply chain, outpatient, patient access, safe patient handling, educators, and fall team leaders from each facility and other partners based on identified issues. The team has revised the System-wide policy and electronic education plan that was developed for both clinical and non-clinical staff. Fall reduction and prevention is everyone's responsibility. The System Fall team identified the minimum membership for the local fall team to include: Safe Patient Handling (SPHM) and Fall Team (Co-chairs), Quality Director, Patient Safety Officer, Educators, Physical Therapy, Nursing Leadership with Representation From Each Unit, Bedside staff representation, Logistics/Transportation, CMO, Pharmacist, and CNEO (Executive Sponsor). Ad Hoc: Materials Management, Engineering, and other disciplines as needed. Each organization is provided access to their data with both a monthly data dashboard and a process dashboard to track trends and process compliance. Fall reduction interventions include the use of a fall bundle (yellow slippers, blanket, wristband, signage, fall mat). In addition, each facility has patient beds with fall prevention features, bed/chair alarms and safety attendant expectations. Additionally, facilities have in place or are piloting: commode alarms, camera monitoring, nurse call systems,
Action Plan:
Monthly Dignity Health Fall Team WebEx Meetings
Monthly Fall Shared Learnings
Monthly Facility Fall Team Meetings
Trending data and comparison data provided by hospital to include but not limited to: location, date/time, shift, patient status, patient activity, interventions
Fall debrief reviews completed for each fall
Pilot programs including but not limited to: cohorting beds with fall prevention features, #days since last fall, camera monitoring, computer alert aids, bed/chair alarms synced to nurse call or phone system
Top 5 facilities with the greatest opportunities to partner with like-facilities with success fall prevention programs Commitment Timeline:
3 month - Data and Process Dashboards populated and discussed at both the Dignity Health Fall Team and Facility Fall Team monthly meetings. Implementation of the #days since last fall program; Ongoing fall policy education and unit based observations to ensure practice reflects policy; review of fall data and identify additional strategies and interventions
6 month - Review of cohorting of bed pilot data to determine efficacy and to determine strategies for implementation in other facilities; review of fall data and identify additional strategies and interventions; Fall Prevention Program review to determine effectiveness of current plan or rapid cycle improvement strategies
9 months - Dignity Health Fall Team performance improvement activities and program evaluation to determine next steps necessary to "getting to zero"
12 months - Fall Program Evaluation
Impact Details
Lives Saved
Lives Saved predicted:
0.6600000000000002 For reporting purposes, the number has been rounded up to the nearest whole number. Lives Saved predicted:
1
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Dignity Health |
CA |
US |
Dignity Health Commits to Reducing Low Risk Cesarean Birth Rates
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Dignity Health
Dignity Health Commits to Reducing Low Risk Cesarean Birth Rates
Contact Info
Name: Suzanne Wiesner
Phone: 9168512789
Email: suzanne.wiesner@dignityhealth.org
Position: Director, Maternal Child Health Services
Organization Name: Dignity Health
Organization Address:
185 Berry Street , Suite 300
San Francisco, CA 94107 US
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 11C - Reducing Unnecessary Cesarean Sections (C-Sections)
Commitment Name:
Dignity Health Commits to Reducing Low Risk Cesarean Birth Rates
How Many Hospitals Will This Commitment Represent? 29 Commitment Summary:
Safely reducing the cesarean delivery rate is an important priority for maternity care providers and facilities. As national cesarean rates continue to rise, the development of strategies to reduce cesarean delivery in low-risk women provides an opportunity to improve quality and safety among women and newborns. “Although cesarean delivery can be life-saving for the fetus, the mother, or both in certain cases, the rapid increase in the rate of cesarean births without evidence of concomitant decreases in maternal or neonatal morbidity or mortality raises significant concern that cesarean delivery is overused. Therefore, it is important for health care providers to understand the short-term and long-term tradeoffs between cesarean and vaginal delivery, as well as the safe and appropriate opportunities to prevent overuse of cesarean delivery, particularly primary cesarean delivery.” Safe Prevention of Primary Cesarean Delivery, ACOG, 2014. Commitment Description & Detail:
The safe reduction of low-risk cesarean birth will be measured by a risk-adjusted methodology which excludes women with prior cesarean delivery and with high risk diagnoses using methodology recommended by the Society for Maternal Fetal Medicine (SMFM). Balancing measures are monitored and include unexpected newborn complication rate, birth trauma and maternal trauma. The focus on a risk-adjusted population aims to assist Dignity Health in reaching the Healthy People 2020 goal of reducing Nulliparous Term Singleton Vertex (NTSV) Cesarean rates at or below 23.9%. Reference: Armstrong, J. C., et al., (2016). Society for Maternal-Fetal Medicine (SMFM) Special Report: Comparing variation in hospital rates of cesarean delivery among low-risk women using 3 different measures. American Journal of Obstetrics and Gynecology. February 2016. Action Plan:
The safe reduction of low risk cesarean birth requires a multi-faceted approach. Strategies should be facility-specific and strive to support normal vaginal birth for low risk mothers: Readiness o Standardized education for staff and providers o Physician champion identified Recognition and Prevention o Admission criteria, labor support practices o Second stage management Response (Managing Labor Abnormalities) o Standardized definitions for labor dystocia and other abnormalities Reporting (Using Data to Drive Improvement) o Facility and provider cesarean rates reviewed and shared o Balancing measures reviewed and shared
Commitment Timeline:
Efforts to safety reduce the rate of low risk cesarean birth are ongoing. We will continue these efforts until all of our hospitals successfully achieve the Health People 2020 goal.
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Dignity Health |
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Reducing Morbidity and Mortality in OB Patients with Severe Hypertension
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Commitment
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Dignity Health
Reducing Morbidity and Mortality in OB Patients with Severe Hypertension
Contact Info
Name: Suzanne Wiesner
Phone: 9168512789
Email: suzanne.wiesner@dignityhealth.org
Position: Director, Maternal Child Health Services
Organization Name: Dignity Health
Organization Address:
185 Berry Street , Suite 300
San Francisco, CA 94107 US
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 11B - Severe Hypertension in Pregnancy and Postpartum
Commitment Name:
Reducing Morbidity and Mortality in OB Patients with Severe Hypertension
How Many Hospitals Will This Commitment Represent? 29 Commitment Summary:
Hypertensive disorders of pregnancy are the leading cause of maternal mortality and one of the leading contributors to premature birth that leads to significant neonatal morbidity and mortality (ACOG, 2012). Guidelines have been proposed to increase early recognition and treatment of patients with severe blood pressures during the antepartum, intrapartum and postpartum periods.
Commitment Description & Detail:
In response to rising trends in maternal morbidity and mortality, the California Maternal Quality Care Collaborative (CMQCC) and the Preeclampsia Task Force developed a toolkit titled, “Improving Health Care Response to Preeclampsia.” Dignity Health supported the implementation of this toolkit - key areas of standardization and focus were identified by a multidisciplinary workgroup and a system-wide toolkit rolled out in 2014. We continue to support these guidelines in an effort to improve outcomes related to hypertension in pregnancy.
Action Plan:
A standardized process for early recognition and treatment has been implemented at all 29 facilities with obstetric services. Compliance with a hypertension bundle is measure and compliance reported using an \"all or none\" methodology (ie. all elements must be documented for the record to be compliant). The bundle elements include the following: 1. Treatment of confirmed and sustained Blood Pressure Trigger (Systolic ≥ 160 and/or Diastolic ≥ 110) within 1 hour of confirmed blood pressure. 2. Administration of magnesium sulfate for seizure prophylaxis. 3. Discharge appointment scheduled within guidelines.
Commitment Timeline:
Bundle compliance is measure for each facility. We will continue to focus on hypertension in pregnancy.
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Dignity Health |
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Reducing Morbidity and Mortality in Patients with Obstetrical Hemorrhage
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Commitment
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Dignity Health
Reducing Morbidity and Mortality in Patients with Obstetrical Hemorrhage
Contact Info
Name: Suzanne Wiesner
Phone: 9168512789
Email: suzanne.wiesner@dignityhealth.org
Position: Director, Maternal Child Health Services
Organization Name: Dignity Health
Organization Address:
185 Berry Street , Suite 300
San Francisco, CA 94107 US
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 11A - Postpartum Hemorrhage (PPH)
Commitment Name:
Reducing Morbidity and Mortality in Patients with Obstetrical Hemorrhage
How Many Hospitals Will This Commitment Represent? 29 Commitment Summary:
Obstetrical hemorrhage continues to be a major source of maternal morbidity and mortality in the United States. The incidence of abnormal placentation appears to be on the rise, which is a major cause of hemorrhage. Delays in recognition of maternal compromise, and delays in treatment, are often contributing factors. Commitment Description & Detail:
Implementation of a standardized, comprehensive protocol was implemented at all 29 facilities with obstetric services. A comprehensive approach to improvement includes education and training for all staff and providers who care for obstetrical patients. Action Plan:
Compliance with the obstetrical hemorrhage bundle is measured on an ongoing basis. The methodology for compliance includes an \"all or none\" approach to care, requiring that all elements of the bundle are documented in order for the record to be compliant. The bundle elements include: • Hemorrhage Risk assessed and documented on admission • Correct blood bank lab based on Hemorrhage Risk • Blood and clots weighed per protocol • DIC panel drawn for Stage 2 & 3 • If Stage 3, blood products given according to protocol Commitment Timeline:
Compliance with the obstetrical hemorrhage bundle is ongoing, and will continue as long as there is opportunity for improvement.
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Dignity Health |
CA |
US |
Monitoring for Opioid-Induced Respiratory Depression
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Commitment
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Dignity Health
Monitoring for Opioid-Induced Respiratory Depression
Contact Info
Name: Candace Fong
Phone: 9168389236
Email: candace.fong@dignityhealth.org
Position: System Director of Pharmacy and Medication Safety
Organization Name: Dignity Health
Organization Address:
3400 Data Dr
Rancho Cordova, CA 95670 US
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 4 - Monitoring for Opioid-induced Respiratory Depression
Commitment Name:
Monitoring for Opioid-Induced Respiratory Depression
How Many Hospitals Will This Commitment Represent? 38 Commitment Summary:
Opioid induced respiratory depression is a leading cause of totally preventable patient death (Joint Commission, 2012; ISMP, 2007; Weinger et al., 2011). It also causes serious patient harm. Patients receiving opioids in the hospital have almost twice the incidence of cardiorespiratory arrest compared to other patients (Overdyk et al., 2016). Commitment Description & Detail:
Dignity Health has adopted a multi pronged approach to managing opioid induced respiratory depression. The system opioid stewardship steering committee serves as an \"umbrella\" to provide over site for the multiple efforts (over sedation and abuse) across the organization. Individual efforts have team leads with a standard process of approval, adoption and application into the EHR.
Action Plan:
1. Approval and adoption of multimodal pain order sets 2. Approval and adoption of a single opioid monitoring scale - POSS (Pasero Opioid Induced Sedation Scale) 3. Electronic over sedation app and alert 4. Naloxone usage monitoring through the \"all cause harm\" real time alert system 5. Standardization of the PCA order sets to include required monitoring and opiate naive patient dosing
Commitment Timeline:
In progress with reductions since 2015; and on going
Impact Details
Lives Saved
Methodology for Determining Lives Saved:
Lives saved has not been calculated
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Dignity Health |
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System wide adoption of CANDOR - Communication and Early Resolution
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Commitment
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Dignity Health
System wide adoption of CANDOR – Communication and Early Resolution
Contact Info
Name: Barbara Pelletreau
Phone: 415-438-5567
Email: barbara.pelletreau@dignityhealth.org
Position: Senior Vice President, Patient Safety
Organization Name: Dignity Health
Organization Address:
34 Sanford Lane
Lafayette, CA 94549 US
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 1 - Culture of Safety
Commitment Name:
System wide adoption of CANDOR – Communication and Early Resolution
How Many Hospitals Will This Commitment Represent? 35 Commitment Summary:
Dignity Health is committing to full adoption of CANDOR. By adopting CANDOR, Dignity Health is going beyond traditional \"disclosure\" to training teams to communicate immediately after a serious safety event with family and patient. Also, Dignity Health will formalize the care for the caregiver support programs for clinicians involved with serious safety events. Commitment Description & Detail:
Dignity Health will measure adoption of CANDOR with the following actions at each hospital: 1. Present to Hospital Board, Medical Executive Committee and Leadership 2. Train leadership and directors/managers, including physician leaders 3. Identify team members of the Patient Communication Team 4. Establish WeCare (care for the caregiver) program 5. Track CANDOR events through events reporting system 6. Partner with legal and risk services for CANDOR events 7. Adopt CANDOR practices (no bills to family/patient)
Action Plan:
Dignity Health will do the following to support 100% adoption: 1. Provide training 2. Include a CANDOR event in monthly Shared Learnings call 3. Track CANDOR events 4. Provide system wide policies to support CANDOR principles Commitment Timeline:
December 2020
Impact Details
Lives Saved
Predicted Lives Spared Harm:
85 For reporting purposes, the number has been rounded up to the nearest whole number. Predicted Lives Spared Harm:
85
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Dignity Health |
CA |
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Standardizing and safeguarding the medication use process
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Commitment
×
Dignity Health
Standardizing and safeguarding the medication use process
Contact Info
Name: Candace Fong
Phone: 9168389236
Email: candace.fong@dignityhealth.org
Position: System Director of Pharmacy and Medication Safety
Organization Name: Dignity Health
Organization Address:
3400 Data Dr
Rancho Cordova, CA 95670 US
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 3E - Standardize and Safeguard Medicine Administration
Commitment Name:
Standardizing and safeguarding the medication use process
How Many Hospitals Will This Commitment Represent? 38 Commitment Summary:
Medication errors occur in every aspect of the medication use process. Preventable medication errors can occur during prescribing, dispensing and administration phases of this process. The use of technology as bar code scanning and \"smart\" infusion pumps assist in the prevention of these types of errors. Commitment Description & Detail:
Dignity Health has fully implemented the use of bar code scanning and \"smart\" infusion pump technology. A system dashboard has been developed for each hospital to monitor their \"scan\" rates down to the unit level. Each hospital has a multidisciplinary team to address the scan rates and precipitating causes for failed scans or other challenges from the staff. Additional focus has been placed on \"order hygiene\" for the EHR order sets, technology in the aseptic compounding areas of pharmacy, restrictions with the \"high alert\" medication category as well as internal safety processes with medication storage within the pharmacy as well as the medication dispensing cabinets.
Action Plan:
1. Bar code scan rate - system dashboard established with a 95% scan rate metric. The current system scan rate is 95% but focus is on facilities not at target 2. \"Smart\" infusion pump scan rate - system dashboard established with a 90% scan rate metric. The current system scan rate is 89% with focus on facilities not at target 3. \" Order hygiene\" for order sets to include drop down selections or hyperlinked references 4. Scan technology in the sterile compound area of pharmacy to check and document the compounding process 5. High alert medications have defined criteria for prescribing, ordering, dispensing, administration and monitoring. Commitment Timeline:
Fully implemented and in progress
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Dignity Health |
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Improving Hand Hygiene
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Commitment
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Dignity Health
Improving Hand Hygiene
Contact Info
Name: Roy Boukidjian
Phone: 818-921-0380
Email: Roy.Boukidjian@DignityHealth.org
Position: System Director, Infection Prevention
Organization Name: Dignity Health
Organization Address:
185 Berry st , Suite 300
San Francisco, CA 94107 US
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 2A - Hand Hygiene
Commitment Name:
Improving Hand Hygiene
Commitment Start Date:12/14/2018 How Many Hospitals Will This Commitment Represent? 39 Commitment Summary:
Hand hygiene compliance continues to fluctuate across healthcare settings due to lack of accountability, buy-in, and true understanding of patient impact when hand hygiene is not done. In addition, patient impact is not immediately realized as the adverse event of poor hand hygiene may appear several days later and thus making it difficult in tying the adverse event to one particular moment in time. Commitment Description & Detail:
Dignity Health will work at the system level to develop the expectation of hand hygiene compliance by collaborating with multiple stakeholders and producing standardized tools for system wide implementation. Action Plan:
Dignity Health plans to address the problem by the following actions:
- Standardizing a hand hygiene policy across the system
- Evaluate the capability of obtaining electronic monitoring systems for all facilities
- Revamp how hand hygiene data is presented to staff (e.g., tie it to a patient story)
- Work with senior leadership to enhance accountability (e.g., integrate hand hygiene compliance in performance reviews) Commitment Timeline:
within 12 months of start date
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Dignity Health |
CA |
US |
Elimination of CAUTI
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Commitment
×
Dignity Health
Elimination of CAUTI
Contact Info
Name: Roy Boukidjian
Phone: 818-921-0380
Email: Roy.Boukidjian@DignityHealth.org
Position: System Director, Infection Prevention
Organization Name: Dignity Health
Organization Address:
185 Berry st , Suite 300
San Francisco, CA 93065 US
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 2B - Catheter-associated Urinary Tract Infections (CAUTI)
Commitment Name:
Elimination of CAUTI
How Many Hospitals Will This Commitment Represent? 39 Commitment Summary:
Catheter Associated Urinary Tract Infections (CAUTI) account for 75% of urinary tract infections (UTI) within a healthcare setting. In addition, bacteriuria commonly leads to unnecessary antimicrobial use, and urinary drainage systems are often reservoirs for multidrug-resistant bacteria and a source of transmission to other patients. Over utilization of Foley catheters and inappropriate urine culture testing has been well documented in the literature. Foley catheters are seen as a convenient and efficient device for both healthcare provider and patient as it doesn't require frequent pad changes or ambulation to the bathroom thus maintaining a Foley catheter is seen as a benefit to the front line staff and patients on occasion. Also, The lack of clinical assessment for true UTI is leading to excessive urine cultures that are in return causing inappropriate antibiotic use due to false positive culture results. Commitment Description & Detail:
Dignity Health plans on addressing this concern by standardizing implementation strategies across the system, increasing accountability by placing this measure as part of the board approved annual goals, and working with a multi-disciplinary team (e.g., Lab, Nursing, Supply Chain, etc.) to approach CAUTI prevention from all angles. Action Plan:
Dignity Health will perform the following:
- Produce a gap analysis on all evidence based practices and require all facilities to review and implement action plans as necessary
- Create distinct and unique strategies for CAUTI prevention and designate nursing executives as the lead for implementation strategy
- Work with laboratory to produce a standardized urine reflex protocol to limit inappropriate testing and antibiotic treatment
- Provide a standardized list of alternatives to Foley catheters to all facilities and require staff education on their use Commitment Timeline:
12 months from start date
Impact Details
Lives Saved
Lives Saved predicted:
0.7624500000000003 For reporting purposes, the number has been rounded up to the nearest whole number. Lives Saved predicted:
1
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Dignity Health |
CA |
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Early Detection of Sepsis in Emergency Services
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Commitment
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Dignity Health
Early Detection of Sepsis in Emergency Services
Contact Info
Name: Catherine Hesse
Phone: 9167652107
Email: whirlyk8@gmail.com
Position: System Director, Emergency Services
Organization Name: Dignity Health
Organization Address:
3937 Orangewood Drive
Fair Oaks, California 95628 US
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 9 - Early Detection and Treatment Of Sepsis
Commitment Name:
Early Detection of Sepsis in Emergency Services
Commitment Start Date:12/14/2018 How Many Hospitals Will This Commitment Represent? 36 Commitment Summary:
Sepsis is often poorly recognized in the Emergency Department upon arrival. It is in the top 10 causes of death in the United States. Early recognition and detection with rapid deployment of evidence based practices such the use of the Sep 1 bundle could save lives if employed more quickly. Commitment Description & Detail:
Dignity Health plans to improve Sepsis recognition within Emergency Services by educating care providers, nurses and physicians to better recognize the signs and symptoms of sepsis in infants, children and adults and take action more quickly. Training, visuals, review of cases with opportunity and education of the public are just a few ways we plan to improve Sepsis care within the Emergency Department. Action Plan:
1. Improve triage accuracy in Emergency Services.
2. Improve the early recognition of Sepsis in adults and children.
3. Place visuals in each emergency department that teach the Sepsis care bundle to practitioners to improve their knowledge.
4. Teach the public how to recognize and care for Sepsis and seek care when ill. Commitment Timeline:
12 month timeline with stepwise fashion of implemetation.
Gradual improvement over time with new Sep 1 guidelines anticpated.
Impact Details
Lives Saved
Predicted Lives Spared Harm:
14 For reporting purposes, the number has been rounded up to the nearest whole number. Predicted Lives Spared Harm:
12
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Secretaría de Salud |
CIUDAD DE MÉXICO |
MX |
Hospital-acquired Pneumonia Prevention Initiative (HAPPI): Prevention of non-ventilator Pneumonia
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Commitment
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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 (pedVAP/PVAP)
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 |
CIUDAD DE MÉXICO |
MX |
El Médico en tu Casa: Home health care in vulnerable population
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Commitment
×
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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Secretaría de Salud |
CIUDAD DE MÉXICO |
MX |
Uso racional del oxígeno en el Recién Nacido Prematuro para la Prevención de Retinopatía del Prematuro y la Broncodisplasia Pulmonar en la Unidad de Cuidados Intensivos Neonatales.1
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Commitment
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Secretaría de Salud
Uso racional del oxígeno en el Recién Nacido Prematuro para la Prevención de Retinopatía del Prematuro y la Broncodisplasia Pulmonar en la Unidad de Cuidados Intensivos Neonatales.1
Contact Info
Name: Enver Pavel Aillon Terceros
Phone: 5541431126
Email: enveraillon@gmail.com
Position: Director Medico
Organization Name: Secretaría de Salud
Organization Address:
Fray Gregorion Jimenez de la Cuenca S/N Barrio de San Antonio
Valle de Bravo, Estado de México 51200 MX
Participants:
-
Ariamne Gomez Gonzalez, Supervisora de enfermeria
APSSHave you reviewed the Patient Safety Movement Foundation's Actionable Patient Safety Solutions (APSS)?
Yes What Patient Safety Challenge does your Commitment address?
Challenge 7A - Optimal Neonatal Oxygen Targeting How Many Hospitals Will This Commitment Represent?
1
Commitment Name:
Uso racional del oxígeno en el Recién Nacido Prematuro para la Prevención de Retinopatía del Prematuro y la Broncodisplasia Pulmonar en la Unidad de Cuidados Intensivos Neonatales.1
Commitment DetailsCommitment Summary:
Con el avance de la tecnología, ha aumentado la supervivencia del recién nacido prematuro de menor de 1250 gr. de peso, y está presentándose en forma creciente el problema de Retinopatía del Prematuro, la cual consiste en el desarrollo anormal de vasos en la retina periférica y de los cuales la mayoría se resuelve espontáneamente. Sin embargo existen algunos que progresan llegando inclusive a la ceguera total o una pérdida sensible de la visión. Este problema es prevenible en un 50% con un tratamiento oportuno a base de cirugía láser y crioterapia. Para poder llegar a este diagnóstico es necesario realizar un tamizaje a todos los prematuros de riesgo que sean atendidos en la Unidad de Cuidados Intensivos Neonatales (UCIN) en el que se requiere la participación de los médicos oftalmólogos, retinólogos, neonatólogos, pediatras, médicos generales, enfermeras especialistas, que con conciencia y compromiso detecten este problema. Sin embrago estos datos estadísticos se desconocen el Hospital General Valle de Bravo, por no contarse con un sistema de registro que permita tener conocimiento del número de recién nacidos que requieren este tamizaje para llevar a cabo una vigilancia y seguimiento de la población en riesgo, al igual por qué no se ha trabajado en este tema ejemplo de ello son los datos estadísticos que se mencionan:
Durante el año 2017 hubo un total de ingresos al servicio de la unidad de cuidados intensivos neonatales de 189 pacientes, de los cuales 64 fueron recién nacidos prematuros, pero no se cuenta con el registro de estos recién nacidos prematuros que hayan ocupado de oxigeno suplementario y mucho menos de si se les realizó un tamizaje en la prevención de la retinopatía.
En el año 2018 se cuenta con un ingreso de 245 y de estos 112 fueron recién nacidos prematuros, a los cuales no hay registro de detección oportuna de la retinopatía y mucho menos un seguimiento médico especializado en oftalmología, cabe mencionar que la mayoría de estos ingresos son foráneos y que anteriormente al momento de su egreso se referían a la región correspondiente a su domicilio.
Dentro de la infraestructura y equipo del área de cuidados intensivos neonatales, no se cuenta con fluxómetros para regulación del oxígeno suplementario.
También se encuentra desabasto en insumos consumibles, como bolsas auto inflables funcionales, mascarillas neonatales anatómicas, puntas nasales neonatales, cámara cefálica neonatal funcionales, tomas de oxigeno suficientes en cada unidad de las tres áreas que corresponden a la unidad de cuidados intensivos neonatales, equipo estuche de diagnóstico para oftalmología.
La falta de difusión de material sobre la oxigenoterapia, las recomendaciones para el control de la saturación de oxígeno óptima en prematuros y la falta de capacitación para el personal de enfermería del servicio de la unidad de cuidados intensivos neonatales continua siendo alta, prueba de ello se mencionan las siguientes mediciones del personal de enfermería:
1. El 100% equivalente a 19 enfermerasdesconocen el concepto y manejo de la retinopatía.
2. El 100% del personal de enfermería desconoce el concepto y manejo de la broncodisplasia pulmonar.
3. El 63% del personal de enfermería desconoce la clasificación del recién nacido de acuerdo a las semanas de gestación.
4. El 21% del personal de enfermería desconoce los signos de dificultad respiratoria.
5. El 78% del personal de enfermería desconoce los parámetros deseados de saturación de oxígeno en el recién nacido prematuro.
6. El 42% del personal de enfermería desconoce la indicación máxima de aporte de oxigeno suplementario en el recién nacido.
7. El 68% del personal de enfermería desconoce el manejo del monitor cardiaco.
8. El 84% (16) el personal de enfermería desconoce las complicaciones que produce el uso irracional de oxigeno suplementario en el recién nacido prematuro.
9. El 100% (19) del personal de enfermería dentro de la unidad de cuidados intensivos neonatales no recibido capacitación en el manejo del recién nacido prematuro y ni en el uso racional del oxígeno suplementario.
10. Se desconoce si el familiar del recién nacido prematuro sabe si el oxígeno puede ocasionarle ceguera a su paciente prematuro.
11. El 100% del personal de enfermería no conoce el lineamiento que habla sobre la detección, diagnóstico y tratamiento de la retinopatía en el recién nacido prematuro en el segundo y tercer nivel de atenciónGPC IMSS-281-10
12. El 100% del personal de enfermería no conoce la guía práctica clínica sobre las intervenciones de enfermería en el recién nacido prematuro IMSS-645-
Por los datos estadísticos antes mencionados, el hospital general valle de bravo iniciara el proyecto:
“Uso racional del oxígeno en el recién nacido prematuro, prevención de la retinopatía del prematuro y bronco displasia pulmonar”. Action Plan:
La falta de uso racional de oxigeno en la UCIN del Hospital General Valle de Bravo, sera mediante la Supervisión trimestral del uso racional del oxígeno, la supervisión al área médica del seguimiento del proceso de la detección, diagnóstico y tratamiento de la retinopatía y broncodisplasia pulmonar, mediante la supervisión y revisión del censo de pacientes a los que se les está realizando el proceso de la detección, diagnóstico y tratamiento de la retinopatía y broncodisplasia pulmonar, se supervisaran y medirán los registros y expedientes de los recién nacidos prematuros, ademas se capacitara al personal medico y de enfermería, después de la capacitación, para saber el impacto de la misma, se supervisara y medirá la aplicación de los parámetros de saturación de oxigeno deseados en servicio con cada uno de los neonatos. Por ultimo se capacitara a los padres de los neonatos en el uso racional de oxigeno, con la finalidad de que ellos participen al vigilar y reportar cuando el oxigeno de su recien nacido no este dentro de los parametros normales. Como difusion se tendrá en el servicio el lineamiento y el proceso, al alcance de todos. Impact Details
Lives Saved
Tell us about your baseline level of harm:
No se cuenta con datos estadísticos confiables que nos indiquen el numero de prematuros que recibieron oxigeno suplementario y adquirieron Retinopatia del prematuro. Next, make a prediction (goal) from your baseline above for 1 year from today. We’ll give you the opportunity to update us next year on the actuals:
Del 100% de pacientes prematuros menores de 32 semanas que recibieron oxigeno suplementario el 80% no desarrollo retinopatia del prematuro. Del 100% de pacientes prematuros menores de 32 semanas que recibieron oxigeno suplementario el 80% fue valorado por oftalmologo. Lives Saved:
15 Lives Spared Harm:
15 Methodology for Determining Lives Saved:
No de pacientes prematuros menores a 32 semanas que desarrollaron retinopatia del prematuro/No de pacientes prematuros menores de 32 semanas que recibieron oxigeno suplementario x 100
No de pacientes prematuros menores de 32 semanas que fueron valorados por el oftalmologo/No de pacientes prematuros menores de 32 semanas que recibieron oxigeno suplementario x 100
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Secretaría de Salud |
CIUDAD DE MÉXICO |
MX |
Planificación de atención colaborativa
View Commitment
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 13B - Collaborative Care Planning in 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 |
CIUDAD DE MÉXICO |
MX |
The enhancement of adverse events report in the Automated Health Incident Registry System (SIRAIS) platform.
View Commitment
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 - 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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The enhancement of adverse events report in the Automated Health Incident Registry System (SIRAIS) platform. - Update - 12.13.18
View Update
Commitment Update
×
Secretaría de Salud
The enhancement of adverse events report in the Automated Health Incident Registry System (SIRAIS) platform. – Update – 12.13.18
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
Commitment Details Commitment Start Date: 01/10/2018 How many hospitals are represented in this commitment?
Last Report
16 |
Current
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 Update:
During 2018, we sought to comply with the initial strategy proposed, which was divided into: stage of promotion, data recovery, definition of priority action lines in patient safety and training in the analysis of adverse events and control panels. We changed the technological platform of reporting from SIRAIS Platform to “SISTEMA NACIONAL DE REPORTE DE EVENTOS ADVERSOS” (NATIONAL SYSTEM OF ADVERSE EVENTS REPORTING), because of the update from the federal health level. First of all, we discovered that there was a general lack of knowledge at the administrative, nursing, medical and operational support areas staff; that is why for us, the first year of participation in the Patient Safety Movement was called: CONSCIOUSNESS AND TRAINING IN PATIENT SAFETY. A first and second phase of training was carried out (first and second semester of 2018); assuming the diversity of locations of the hospitals, it was decided to regionalize the educational exercise to cover the whole, in the first semester the emphasis was: the responsibility of each stakeholder involved in health care, the importance of reliable and safe care, legal concepts of patient safety, topics that were strengthened with the implementation of a distance educational platform on the online moodle domain, in the second semester it was covered information about how to report adverse events and how to implement control panels. According with the importance of the topic, the information was made known in associated events, both in person and through distance platforms (tele-education), bringing as a result a total of 4800 trained people.
By having trained staff it was possible to: a) tropicalize the patient safety information in each hospital in order to cover their recognized needs in patient safety in the observable scenario, b) disseminate information with the rest of the staff and, c) the implementation of mailboxes for the reporting of adverse events was achieved d) to reach innovation from units according to the needs, such as the implementation of identification tables used in each hospital bed. The main impact of the first stage of the project is the change in patient safety culture when reporting 231 adverse events. After this change in the culture of patient safety, in 2019, the program will extend its efforts to quality systems in patient safety that focus on the analysis of the advers events, which will be unified for all hospitals, through state knowledge sharing forums that will generate a state strategy; it will also have as a mission, the expansion of information through publications in magazines and newsletters.
Your commitment aligns with APSS
Challenge 1 - Culture of Safety Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
TO SHARE KNOWLEDGE: For the State of Hidalgo, and all its Hospitals, it was indispensable to permeate with information to all the people involved in health care, knowledge allows to generate awareness thus, implementation of actions in order to correct errors; most of the year was dedicated to the learning curve, not only of the service leaders, but also to people who directly or indirectly impact on patient safety; knowing the basic principles of patient safety, their Implications and awareness of empathy towards patients and their families was an important area of opportunity.
SELF KNOWLEDGE. Through valuable information from regional trainings, each hospital unit reviewed their opportunity areas taking actions to improve and reduce errors, aligned with patient safety according to their statistical information, the task was not easy, due to that there was no record of adverse events about which actions should be taken accordingly.
PARTICULAR STRATEGIES. The culture of patient safety has different branches, based on a general strategy, each hospital raised its particular needs and trained its staff according to the topics with the greatest impact, for example: hand washing, adverse event system, essential actions for patient safety, infections associated with health care, clinical record, use of medications, critical patient care, Biohazardous and Infectious Waste, red car, accreditation card, risks of falls, among others.
USE OF TECHNOLOGY. Distance education corresponds to an important milestone of opportunity, due to the remoteness of some hospitals or health care units, the implementation of adequate use of technology, was essential to reduce the inequality gap, as a result: expand opportunities of valuable knowledge for medical, administrative and operational support staff. The use of technology platforms for the reporting of adverse events served as a key to promote further analysis at a hospital and state level.
Impact Details
| Initial Commitment |
Commitment Update |
Project Next Year |
Lives Lost
0 |
Lives Lost
5 |
Lives Lost:
-225 |
Lives Spared Harm Target
0 |
Actual Lives Spared Harm in last 12 months
277139 |
Lives Spared Harm Target for following calendar year
318368 |
Lives Saved Target
0 |
Actual Lives Saved in last 12 months (might differ from initial target)
230 |
Projected Target of Lives Saved for following calendar to try to finish commitment
276 |
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New Lives Lost (lives lost – actual lives saved)
-225 |
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Secretaría de Salud |
CIUDAD DE MÉXICO |
MX |
Avoiding maternal morbi-mortality.
View Commitment
Commitment
×
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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Avoiding maternal morbi-mortality. - Update - 12.13.18
View Update
Commitment Update
×
Secretaría de Salud
Avoiding maternal morbi-mortality. – Update – 12.13.18
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
Commitment Details Commitment Start Date: 01/10/2018 How many hospitals are represented in this commitment?
Last Report
15 |
Current
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 Update:
The commitment of the health services in Hidalgo is to reduce and / or prevent maternal deaths, the objective was to strength the actions and strategies to avoid severe maternal morbidity. The actions implemented during this year to achieve this objective were to strength the opportunity areas identified to improve.
It was implemented and started the promotion of pre-pregnancy care, aiming to integrate some other specialties such as internal medicine and surgery in the identification of patients of childbearing age with risk factors, prenatal control with a risk approach was improved and training was strengthened in the attention of obstetric emergencies.
It was also developed the systematization of obstetric triage, the activation of the mater code has been strengthened as well as the training and qualification of the teams of immediate obstetric response with the execution of simulations. It was also Followed-up actions focused on improving the reference system.
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
A good practice with excellent results is the execution of mater code simulations in all the hospital shifts of the hospitals, which allows to identify needs of training in the attention of the obstetric emergency as well as to evaluate response capacity in human resources and training field; this exercise identifies team integration time and training, during this year there had been developed 130 simulations. This also supports the reporting of cases of severe maternal morbidity immediately not only to managers but also to the first level of care, which allows to monitor the evolution of the patient in different levels.
There is an important progress in post-obstetric event contraception with high priority in patients with risk; a successful strategy is the employment of exclusive human resources for the post-obstetric event contraception program.
Hidalgo obtained the first place in post-obstetric event contraception in 2017. This year, based on the statistics, the percentage of patients accepting contraceptive methods was increased.
Impact Details
| Initial Commitment |
Commitment Update |
Project Next Year |
Lives Lost
19 |
Lives Lost
9 |
Lives Lost:
-866 |
Lives Spared Harm Target
2072 |
Actual Lives Spared Harm in last 12 months
14696 |
Lives Spared Harm Target for following calendar year
13696 |
Lives Saved Target
0 |
Actual Lives Saved in last 12 months (might differ from initial target)
875 |
Projected Target of Lives Saved for following calendar to try to finish commitment
875 |
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New Lives Lost (lives lost – actual lives saved)
-866 |
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Secretaría de Salud |
CIUDAD DE MÉXICO |
MX |
CIRUGIA SEGURA
View Commitment
Commitment
×
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 - 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 |
CIUDAD DE MÉXICO |
MX |
Reducción de Infecciones Asociadas a Falta de Lavado de Manos
View Commitment
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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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
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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 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
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University of Pittsburgh Medical Center |
PA |
US |
Getting to Zero-Eliminating Preventable Death from VTE
View Commitment
Commitment
×
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:
-
Josh Levenson, Physician-Heart Vascular Institute
-
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 |
Antimicrobial Stewardship
View Commitment
Commitment
×
University of Pittsburgh Medical Center
Antimicrobial Stewardship
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 Boulevard, Suite 230
Pittsburgh, PA 15213 US
Participants:
APSSHave you reviewed the Patient Safety Movement Foundation's Actionable Patient Safety Solutions (APSS)?
Yes What Patient Safety Challenge does your Commitment address?
Challenge 3B - Antimicrobial Stewardship How Many Hospitals Will This Commitment Represent?
13
Commitment Name:
Antimicrobial Stewardship
Commitment DetailsCommitment Summary:
Antimicrobial overuse is a significant problem for patients due to adverse events and increased rates of antibiotic resistance associated with overuse. Action Plan:
Health System support to individual hospitals
Monthly monitoring and reporting of antibiotic use to individual hospitals with comparison to other UPMC hospitals
Data driven targeted interventions at individual hospitals
Education and support to local pharmacists and providers and individual hospitals
Antibiograms at individual hospitals
System-wide formulary restrictions
Auto renal dosing policy at all hospitals Impact Details
Lives Saved
Next, make a prediction (goal) from your baseline above for 1 year from today. We’ll give you the opportunity to update us next year on the actuals:
This is a new program at UPMC. We will have more data to determine lives saved and harm spared next year. Methodology for Determining Lives Saved:
We will monitor impact by measuring antibiotic usage at individual hospitals as well as the entire system. We will use this as a surrogate marker for improved care.
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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
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University of Pittsburgh Medical Center |
PA |
US |
Reduce the mortality rate of our patients with Sepsis and Septic Shock
View Commitment
Commitment
×
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:
-
Dr. Daniel Glunk, V.P. and Chief Quality Officer
-
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 |
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:
-
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 |
PA |
US |
Getting to Zero – Eliminating Surgical Site Infections
View Commitment
Commitment
×
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:
-
UPMC System Infection Control Committee members and multidisciplinary representatives from each UPMC facility.
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 2C - Surgical site infections (SSI)
Commitment Name:
Getting to Zero – Eliminating Surgical Site Infections
How Many Hospitals Will This Commitment Represent? 1
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.
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 2 Methodology for Determining Lives Saved:
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Getting to Zero – Eliminating Surgical Site Infections - Update - 08.23.18
View Update
Commitment Update
×
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 |
PA |
US |
Getting to Zero – Eliminating Central Line Associated Blood Stream Infections
View Commitment
Commitment
×
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:
-
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
×
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
|
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 |
PA |
US |
Reducing Failed Transitions
View Commitment
Commitment
×
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
View Update
Commitment Update
×
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
|
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 |
PA |
US |
The Patient Blood Management Program of UPMC (PBM) - Improving the Quality and Safety of Patient Care, while reducing the cost per capita of healthcare
View Commitment
Commitment
×
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
-
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 - 11.28.18
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Commitment Update
×
UPMC
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 – 11.28.18
Contact Info
Name: Mary Kay Wisniewski
Phone: (412) 802-8066
Email: wisniewskimk@upmc.edu
Position: Corporate Improvement Specialist and Coordinator of the Patient Blood Management Program at UPMC
Organization Name: UPMC
Commitment Details Commitment Start Date: 01/01/2019 How many hospitals are represented in this commitment?
Last Report
12 |
Current
17 |
Action Plan:
The UPMC Healthcare Enterprise is committed to continuing the Patient Blood Management journey to achieve improved patient outcomes and safety at a lower cost per capita. As an ever-growing and complex organization, we continue to adapt our program to meet systematic PBM spread and foster communities of learning. We have added a new Bloodless Medical Management program to identify anemia sooner, so that treatment and management are proactively addressed. Each hospital within the enterprise contributes to the success of the program and our patients are our key benefactors.
Action Plan
1) Continue to develop the newly structured Bloodless Medical management model and expand anemia surveillance beyond bloodless medicine patients.
2) Continue to monitor quality reports for non-evidenced based transfusion practices and preventable waste incidents and identify opportunities to for continued quality improvement.
3) Develop an educational PBM program for General Medical Education (GME) for medical residents and APP students. Goal to reduce unwarranted blood transfusions by 10% and reduce waste 5% within the next year.
Commitment Update:
Our strategic approach is based on a six-point strategy developed by our program's medical director, Dr. Jon Waters.
1. Leverage computerized physician order entry (CPOE) systems to guide evidence-based transfusions
2. Reduce all forms of waste related to blood transfusion practices
3. Promote alternative blood transfusion methods and systems
4. Promote anemia management strategies
5. Limit iatrogenic blood loss
6. Provide blood management education, awareness and auditing for clinicians; in addition to patient centered shared decision making tools This PBM framework provides flexibility in developing on-going initiatives to enhance the programs success. In March of 2018, a Bloodless Medical Management Program was developed to enable each enterprise hospital to maintain an in-house group of Hospitalist who serve as medical consultants for patients who refuse blood transfusions for personal or religious reasons. This program is the springboard for a concerted approach to anemia management for all hospitalized patients.
Our bloodless medicine patients have emphasized the need to address anemia early on and this concept has translated to an overall appreciation of the salience of this disease. Pre-surgical anemia is a frequently occurring event, leaving patients vulnerable for intra or post operative transfusion. Again, moving from reactive to proactive the PBM medical leadership
developed a pre-surgical algorithm to identify and appropriately treat the anemia prior to
an elective surgical case.
2018 Achievements: 1. 12% RBC,18% FFP, 14% Platelet reduction
in in-warranted transfusion orders. (Evidenced by orders heeded/orders alerted) 2.
Experienced the lowest blood waste rates since PBM program established in 2013. RBC:
0.42% FFP: 0.59% Platelet: 1.40% 3. Blood and Blood Component Purchases reductions
compared to previous year: RBC: -7.0% FFP: -22% Platelet: -1.0%
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
As members of the APSS Patient Blood Management Team we were provided the opportunity to share our program's successful approaches to a global audience. More importantly, we have been able to take a step back and revisit initiatives to ensure sustainability.
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
|
Lives Spared Harm Target for following calendar year
10 |
Lives Saved Target
|
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 Pittsburgh Medical Center |
PA |
US |
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
×
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:
-
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
-
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?
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 |
PA |
US |
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:
-
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
-
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 |
PA |
US |
Best Code Airway Management
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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:
-
Steven Orebaugh, MD, Professor of Anesthesiology, UPMC
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 8A - Safer Airway Management
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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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 - 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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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 13B - Collaborative Care Planning in 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 3A - Medication Errors
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?
Paediatric and Neonatal care
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 2B - Catheter-associated Urinary Tract Infections (CAUTI)
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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Changhua Christian Hospital |
Changhua |
TW |
Airway Safety
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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)
View Commitment
Commitment
×
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 2B - Catheter-associated Urinary Tract Infections (CAUTI)
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
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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 - 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 - 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
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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
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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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Hand-off Communications - Update - 09.02.18
View Update
Commitment Update
×
Changhua Christian Hospital
Hand-off Communications – 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:
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 Update:
We introduce ISBAR skill as standardized critical content is communicated between health care practitioners during handovers of patient care and implement “ticket-to-ride” handover sheet as standardized forms, tools, or methods support a consistent and complete handover process. We build handover information system to offer more convenient and correct information to handover process and improve compliance rate from 88% to 97%.
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
Best practice learn from Actionable Patient Safety Solution APSS #6:
HAND-OFF COMMUNICATIONS. We build handover information system to offer more convenient and correct information to handover process and improve compliance rate from 88% to 97%.
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)
0 |
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 |
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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Coscami S.A. de C.V. |
QUERÉTARO |
MX |
Prevención de caídas
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Commitment
×
Coscami S.A. de C.V.
Prevención de caídas
Contact Info
Name: Ramon Soto
Phone: 01 427 272 1642
Email: ramonsotor@hotmail.com
Position: Director General
Organization Name: Coscami S.A. de C.V.
Organization Address:
Av. Río Moctezuma no. 176
San Juan del Río, QUERÉTARO 76807 MX
Commitment Details What Patient Safety Challenge does your Commitment address?
Challenge 14 - Falls and Fall Prevention
Commitment Name:
Prevención de caídas
How Many Hospitals Will This Commitment Represent? 1
Action Plan
Agendar sesiones informativas con los miembros de Espartanos Grupo Médico.
Publicar carteles y tripticos que den a conocer el proyecto.
Calendarizar sesiones educativas con el fin de capacitar al personal de salud.
Emplear el modelo de gestión de John Kotter (1. Crear sentido de urgencia. 2 Formar una coalición. 3 Crear visión para el cambio. 4 Comunicar la visión. 5 Eliminar los obstáculos. 6 Asegurarse de logros a corto plazo. 7 Construir sobre el cambio. 8 Anclar el cambio a la cultura del hospital).
Generar indicadores de estructura , proceso y resultado que nos ayuden a medir el impacto y a la vez nos permitan generar nuevas estrategias de mejora.
Commitment Timeline
enero-febrero-marzo: Capacitación
abril: Evaluación
mayo: Reingenieria de procesos en caso de de ser necesaria
junio-julio-agosto: Capacitación
septiembre: Evaluación
octubre: Reingenieria de procesos en caso de ser necesaria
noviembre: Capacitación
diciembre: Evaluación anual
Impact Details Lives Lost in Last Calendar Year: 3 How many lives do you expect to spare from harm in the next calendar year 80 How many lives do you expect to save in the next calendar year 80 Methodology for Determining Lives Saved:
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Coscami S.A. de C.V. |
QUERÉTARO |
MX |
Compromiso de la persona y familia
View Commitment
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