View All Commitments | Patient Safety Movement

What does it Mean to Make a Commitment to 0X2020^TM?

We don’t ask for a financial contribution to our Movement because we are looking for organizations to Take Action! We ask that you recognize the severity of the challenges facing your organization today and make a Commitment to solving the issues at hand by eagerly contributing to enduring solutions.

Rather than directly implementing projects, the Patient Safety Movement facilitates action by helping committed organizations connect, collaborate and make effective and measurable Commitments to Action. A commitment expedites action through accountability and shared learning.

Specifically, we ask you to implement at least one of the Actionable Patient Safety Solutions (APSS), developed collaboratively by the Patient Safety Movement and other healthcare leaders, or develop your own commitment to a different challenge. New commitments are highlighted at our annual Summit and organizations that make a commitment are offered special access and savings at the event.

Proactive healthcare organizations dedicated to improving patient safety at their institutions set the stage for action at our annual Summits by establishing their own Commitments. Below are their actionable commitments to reduce preventable patient harm and death within their own organizations.

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Commitment Updates

Parrish Medical Center

Pediatric Adverse Drug Events View Commitment

Hand Hygiene View Commitment

Medication Errors View Commitment

Sustaining a Culture of Safety View Commitment

Sustaining a Culture of Safety – Update – 01.30.18 View Update

Parrish Medical Center

Sustaining a Culture of Safety – Update – 01.30.18

Contact Info

Name: edwin loftin

Phone: 321-268-6120

Email: edwin.loftin@parrishmed.com

Position: VP Acute Care/ CNO

Organization Name: Parrish Medical Center

Commitment Details

Commitment Start Date: 05/21/2002

How many hospitals are represented in this commitment?

Last Report
1

Current
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 Update:
PMC’s Board of Directors have used the Joint Commission tool Oro 2.0 to evaluate the effectiveness of our Culture of Choice and Culture of Safety. In addition PMC has implemented seven specific culture teams to conduct performance improvement work on items such as: safety, recruitment, retention, ideas for change, and effective rounding.

Your commitment aligns with APSS
Challenge 1 - Creating a Culture of Safety

Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
• Person and Family Engagement APSS • Zero harm Board philosophy • PFAC- Patient and Family Advisory Committee • Lean/Sigma • Transparent reporting

Impact Details

Initial Commitment	Commitment Update	Project Next Year
Lives Lost 00	Lives Lost 00	Lives Lost: 38
Lives Spared Harm Target 00	Actual Lives Spared Harm in last 12 months 38	Lives Spared Harm Target for following calendar year 45
Lives Saved Target 00	Actual Lives Saved in last 12 months (might differ from initial target) 38	Projected Target of Lives Saved for following calendar to try to finish commitment 45
	New Lives Lost (lives lost – actual lives saved) 38

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Transitions in Caring View Commitment

Transitions in Caring - Update - 01.30.18 View Update

Parrish Medical Center

Transitions in Caring – Update – 01.30.18

Contact Info

Name: Edwin Loftin

Phone: 3212686120

Email: edwin.loftin@parrishmed.com

Position: VP Acute Care/ CNO

Organization Name: Parrish Medical Center

Commitment Details

Commitment Start Date: 08/03/2010

How many hospitals are represented in this commitment?

Last Report
1

Current
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 Update:
- Established HOC core team - Reviewed current and PSMF HOC checklists - Provided education for all those involved in HOC - Evaluated plan for support utilization

Your commitment aligns with APSS
Challenge 6 - Hand-off Communications

Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
SBAR form Recently accepted to the Patient Safety Movement “ED to Med/Surg Safe Hand-off Checklist” Safe Discharge Checklist (Code Salmon sheet) Nurse documentation within the EMR, “Transfer: Handoff Report PRN”

Impact Details

Initial Commitment	Commitment Update	Project Next Year
Lives Lost	Lives Lost	Lives Lost: 0
Lives Spared Harm Target 6000	Actual Lives Spared Harm in last 12 months 5	Lives Spared Harm Target for following calendar year 5
Lives Saved Target	Actual Lives Saved in last 12 months (might differ from initial target) 5	Projected Target of Lives Saved for following calendar to try to finish commitment 5
	New Lives Lost (lives lost – actual lives saved) 0

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Venous Thromboembolism (VTE) View Commitment

Venous Thromboembolism (VTE) – Update – 01.29.18 View Update

Parrish Medical Center

Venous Thromboembolism (VTE) – Update – 01.29.18

Contact Info

Name: edwin loftin

Phone: 321-268-6120

Email: edwin.loftin@parrishmed.com

Position: VP Acute Care/ CNO

Organization Name: Parrish Medical Center

Commitment Details

Commitment Start Date: 03/01/2015

How many hospitals are represented in this commitment?

Last Report
1

Current
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 Update:
- Establish interdisciplinary team - Establish concurrent chart review process / procedures - Establish appropriate chart review tool - Establish appropriate tool to be used for RCA of outliers

Your commitment aligns with APSS
Challenge 12 - Embolic Events

Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
- VTE Risk assessment completed on all patients at admission and daily - All patients triaged into low, medium, and high risk categories - EHR prompts for providers to order VTE prophylaxis - VTE risk assessment incorporated into nursing admission order sets/intervention - Encouraging highest level of patient mobility as tolerated

Impact Details

Initial Commitment	Commitment Update	Project Next Year
Lives Lost 0	Lives Lost 0	Lives Lost: -1
Lives Spared Harm Target 0	Actual Lives Spared Harm in last 12 months 1	Lives Spared Harm Target for following calendar year 1
Lives Saved Target 0	Actual Lives Saved in last 12 months (might differ from initial target) 1	Projected Target of Lives Saved for following calendar to try to finish commitment 1
	New Lives Lost (lives lost – actual lives saved) -1

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Access To Acute Psychiatric Beds View Commitment

Access To Acute Psychiatric Beds – Update – 01.29.18 View Update

Parrish Medical Center

Access To Acute Psychiatric Beds – Update – 01.29.18

Contact Info

Name: edwin loftin

Phone: 321-268-6120

Email: edwin.loftin@parrishmed.com

Position: VP Acute Care/ CNO

Organization Name: Parrish Medical Center

Commitment Details

Commitment Start Date: 03/01/2016

How many hospitals are represented in this commitment?

Last Report
1

Current
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 Update:
We have changed our commitment to include the evaluation of current technology solutions to include web-based and mobile application psychiatric bed registry that serves as a platform for inpatient hospital bed openings. We will collaborate with key stake-holders in the community/county for interest, feasibility, implementation and support of a shared registry tool.

Your commitment aligns with APSS
Challenge 13B - Mental Health

Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
- Utilization of internal centralized bed placement system. - Established a communication/command center called, “Mission Control” centrally monitoring patient placement. - Providing 1:1 patient care sitters with all Baker Acts within the ED and inpatient setting. - Accessing a trained social work, the 2-1-1 navigator who provides assistance to Brevard County residents to access supportive programs and resources. -Continued community collaboration and planning for access to supportive resources to meet the increased psych patient population needs.

Impact Details

Initial Commitment	Commitment Update	Project Next Year
Lives Lost 0	Lives Lost 0	Lives Lost: 0
Lives Spared Harm Target 0	Actual Lives Spared Harm in last 12 months 1	Lives Spared Harm Target for following calendar year 1
Lives Saved Target 0	Actual Lives Saved in last 12 months (might differ from initial target) 1	Projected Target of Lives Saved for following calendar to try to finish commitment 1
	New Lives Lost (lives lost – actual lives saved) 0

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Optimizing Obstetrical Safety Specifically In The Area Of Hypertensive Disorders of Pregnancy View Commitment

Optimizing Obstetrical Safety Specifically In The Area Of Hypertensive Disorders of Pregnancy – Update – 01.29.18 View Update

Parrish Medical Center

Optimizing Obstetrical Safety Specifically In The Area Of Hypertensive Disorders of Pregnancy – Update – 01.29.18

Contact Info

Name: edwin loftin

Phone: 321-268-6120

Email: edwin.loftin@parrishmed.com

Position: VP Acute Care/ CNO

Organization Name: Parrish Medical Center

Commitment Details

Commitment Start Date: 07/01/2016

How many hospitals are represented in this commitment?

Last Report
1

Current
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 Update:
- Completed review of literature: AWHONN and AGOG standards - Continuing to review policies and procedures - Collaborating with physicians to provide a standardized treatment plan for patients presenting with risk factors or indications suggesting hypertensive disorders in pregnancy - Educating staff to recognize risk factors and indications suggesting hypertensive disorders in pregnancy

Your commitment aligns with APSS
Challenge 11 - Optimizing Obstetric Safety

Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
Following best practices we are looking at changing practice and following protocols for the early detection and management of hypertensive disorders in pregnancy. Our biggest challenge has been buy in from all physicians. We currently have a group of 6 physicians in our Parrish Obstetrics group with different backgrounds and experiences and 6 different ways of treating hypertensive disorders in pregnancy so standardizing practice is going to be our main focus. We will address this at our next OB/GYN Department meeting.

Impact Details

Initial Commitment	Commitment Update	Project Next Year
Lives Lost 0	Lives Lost 0	Lives Lost: 0
Lives Spared Harm Target 0	Actual Lives Spared Harm in last 12 months 2	Lives Spared Harm Target for following calendar year 2
Lives Saved Target 0	Actual Lives Saved in last 12 months (might differ from initial target) 2	Projected Target of Lives Saved for following calendar to try to finish commitment 2
	New Lives Lost (lives lost – actual lives saved) 0

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Neonatal Oxygen Targeting View Commitment

Neonatal Oxygen Targeting – Update – 01.29.18 View Update

Parrish Medical Center

Neonatal Oxygen Targeting – Update – 01.29.18

Contact Info

Name: edwin loftin

Phone: 321-268-6120

Email: edwin.loftin@parrishmed.com

Position: VP Acute Care/ CNO

Organization Name: Parrish Medical Center

Commitment Details

Commitment Start Date: 10/01/2011

How many hospitals are represented in this commitment?

Last Report
1

Current
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 Update:
- Process has been identified and researched - Procedure was revised in March 2017 - Staff has been educated - Continuation of data collection

Your commitment aligns with APSS
Challenge 7 - Neonatal Safety

Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
Following the best practices of using heated humidified oxygen via an oxygen blender, and setting alarm parameters, and using pulse oximetry to guide the optimal and safe use of oxygen to reduce complications such as ROP is our constant focus. The biggest lesson learned is involving physicians in the implementation and changing of protocols. (One of our Pediatricians tends to order oxygen based on symptoms instead of using pulse ox to guide the need for increased oxygen.) We will take this to our next Pediatrics Department Meeting.

Impact Details

Initial Commitment	Commitment Update	Project Next Year
Lives Lost 0	Lives Lost 0	Lives Lost: 0
Lives Spared Harm Target 0	Actual Lives Spared Harm in last 12 months 1	Lives Spared Harm Target for following calendar year 1
Lives Saved Target 0	Actual Lives Saved in last 12 months (might differ from initial target) 1	Projected Target of Lives Saved for following calendar to try to finish commitment 1
	New Lives Lost (lives lost – actual lives saved) 0

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Anemia and Blood Transfusions View Commitment

Anemia and Blood Transfusions – Update – 01.29.18 View Update

Parrish Medical Center

Anemia and Blood Transfusions – Update – 01.29.18

Contact Info

Name: edwin loftin

Phone: 321-268-6120

Email: edwin.loftin@parrishmed.com

Position: VP Acute Care/ CNO

Organization Name: Parrish Medical Center

Commitment Details

Commitment Start Date: 05/26/2011

How many hospitals are represented in this commitment?

Last Report
1

Current
1

Action Plan:
See Above

Commitment Update:
Action items by Blood Management Committee include: - Transfusion not meeting criteria review - Single unit transfusions - Implement blood conservation modalities - Reduction and frequency of blood draws including discard of or hold volumes - Preoperative management of platelet inhibitors and other anticoagulants - Red cell recovery in the operating room

Your commitment aligns with APSS
Challenge 5 - Anemia and Transfusions

Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
Cellsaver in OR where/when applicable. Monitoring Single versus Two Unit orders/transfusions. Patient Blood Transfusion Committee in place. Blood order sets in place, with thresholds for when to give or reasoning is needed. Follow-up letters for inappropriate orders for blood sent to ordering MD’s. Ongoing education.

Impact Details

Initial Commitment	Commitment Update	Project Next Year
Lives Lost 0	Lives Lost 0	Lives Lost: 0
Lives Spared Harm Target 0	Actual Lives Spared Harm in last 12 months 1	Lives Spared Harm Target for following calendar year 1
Lives Saved Target 0	Actual Lives Saved in last 12 months (might differ from initial target) 1	Projected Target of Lives Saved for following calendar to try to finish commitment 1
	New Lives Lost (lives lost – actual lives saved) 0

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FAILURE TO RESCUE: MONITORING FOR OPIOID INDUCED RESPIRATORY DEPRESSION View Commitment

FAILURE TO RESCUE: MONITORING FOR OPIOID INDUCED RESPIRATORY DEPRESSION – Update – 01.29.18 View Update

Parrish Medical Center

FAILURE TO RESCUE: MONITORING FOR OPIOID INDUCED RESPIRATORY DEPRESSION – Update – 01.29.18

Contact Info

Name: edwin loftin

Phone: 321-268-6120

Email: edwin.loftin@parrishmed.com

Position: VP Acute Care/ CNO

Organization Name: Parrish Medical Center

Commitment Details

Commitment Start Date: 10/01/2012

How many hospitals are represented in this commitment?

Last Report
1

Current
1

Action Plan:
See above

Commitment Update:
- Repeat FMEA to assess for additional opportunities - Perform Performance Improvement plan using the DMAIC process

Your commitment aligns with APSS
Challenge 4 - Failure to Rescue: Monitoring for Opioid Induced Respiratory Depression

Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
1. CPOE a. Order strings with preset doses b. Dosage checks/alerts 2. Nursing assessment a. PASERO assessment prior to and after administration 3. Monitoring of Naloxone use for opioid reversal

Impact Details

Initial Commitment	Commitment Update	Project Next Year
Lives Lost 0	Lives Lost 0	Lives Lost: 0
Lives Spared Harm Target 0	Actual Lives Spared Harm in last 12 months 12	Lives Spared Harm Target for following calendar year 12
Lives Saved Target 0	Actual Lives Saved in last 12 months (might differ from initial target) 12	Projected Target of Lives Saved for following calendar to try to finish commitment 12
	New Lives Lost (lives lost – actual lives saved) 0

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Airway Safety View Commitment

Airway Safety – Update – 01.29.18 View Update

Parrish Medical Center

Airway Safety – Update – 01.29.18

Contact Info

Name: edwin loftin

Phone: 321-268-6120

Email: edwin.loftin@parrishmed.com

Position: VP Acute Care/ CNO

Organization Name: Parrish Medical Center

Commitment Details

Commitment Start Date: 10/01/2015

How many hospitals are represented in this commitment?

Last Report
1

Current
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 Update:
- Continue to modify and develop Failed Airway protocol, airway cart/box and equipment system, hardwire and maintain EBP critical practices - Continue to educate team with competencies for protocol, equipment and critical practices

Your commitment aligns with APSS
Challenge 8 - Airway Safety

Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
- Assess airway security every shift by both Respiratory and Nurses - Team communication and collaboration with plan - Pre-oxygenation with every intubation - Waveform Capnography – Immediately following all intubations - System for appropriate sedation and patient restraints to decrease risk of unplanned extubation (UE) - Implement best practice guidelines for weaning & planned extubation - RL Systems for tracking and analyzing QA, adverse, and near miss events for airway management (airway registry beyond hospital safety reporting system) for all unplanned extubations

Impact Details

Initial Commitment	Commitment Update	Project Next Year
Lives Lost 0	Lives Lost 0	Lives Lost: 0
Lives Spared Harm Target 0	Actual Lives Spared Harm in last 12 months 2	Lives Spared Harm Target for following calendar year 2
Lives Saved Target 0	Actual Lives Saved in last 12 months (might differ from initial target) 2	Projected Target of Lives Saved for following calendar to try to finish commitment 2
	New Lives Lost (lives lost – actual lives saved) 0

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Resuscitation Optimization View Commitment

Resuscitation Optimization – Update – 01.29.18 View Update

Parrish Medical Center

Resuscitation Optimization – Update – 01.29.18

Contact Info

Name: edwin loftin

Phone: 321-268-6120

Email: edwin.loftin@parrishmed.com

Position: VP Acute Care/ CNO

Organization Name: Parrish Medical Center

Commitment Details

Commitment Start Date: 10/01/2010

How many hospitals are represented in this commitment?

Last Report
1

Current
1

Action Plan:
see above

Commitment Update:
- Uses existing Code Blue Committee as steering committee for assess opportunities, identifying and implementing solutions and gathering/reporting of data pertaining to this APSS. - Code Blue cases and Rapid Response calls are monitored weekly and any variances are entered into RL solutions.

Your commitment aligns with APSS
Challenge 10 - Prevention and Resuscitation of In-hospital Cardiac Arrest

Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
- Code blue committee in place. - Rapid Response Team (aka Critical Access Team). - Post code conferences. - ACLS training. BCLS training.

Impact Details

Initial Commitment	Commitment Update	Project Next Year
Lives Lost 0	Lives Lost 0	Lives Lost: 0
Lives Spared Harm Target 0	Actual Lives Spared Harm in last 12 months 25	Lives Spared Harm Target for following calendar year 25
Lives Saved Target 0	Actual Lives Saved in last 12 months (might differ from initial target) 25	Projected Target of Lives Saved for following calendar to try to finish commitment 25
	New Lives Lost (lives lost – actual lives saved) 0

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Maintain Zero Hospital-Acquired Stage III and IV Pressure Ulcers View Commitment

Maintain Zero Hospital-Acquired Stage III and IV Pressure Ulcers – Update – 01.29.18 View Update

Parrish Medical Center

Maintain Zero Hospital-Acquired Stage III and IV Pressure Ulcers – Update – 01.29.18

Contact Info

Name: edwin loftin

Phone: 321-268-6120

Email: edwin.loftin@parrishmed.com

Position: VP Acute Care/ CNO

Organization Name: Parrish Medical Center

Commitment Details

Commitment Start Date: 08/01/2016

How many hospitals are represented in this commitment?

Last Report
1

Current
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 Update:
- PMC maintains a supply of pressure reduction mattress replacements on site - Evaluation of new hospital beds and support surfaces has been completed - Addition members added to PUP team - Improvements to EMR continue to be monitored to enhance nurse compliance and ease of charting

Your commitment aligns with APSS
Other

Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
- Skin Risk Assessment every shift using Braden scores to identify risk for skin breakdown - Individualized Care Plans - Nutritional support - Specialty Support surfaces - Turning and repositioning at least q 2 hours. - Individual treatment plan appropriate to the wound and severity.

Impact Details

Initial Commitment	Commitment Update	Project Next Year
Lives Lost 0	Lives Lost 0	Lives Lost: 0
Lives Spared Harm Target 0	Actual Lives Spared Harm in last 12 months 4	Lives Spared Harm Target for following calendar year 4
Lives Saved Target 0	Actual Lives Saved in last 12 months (might differ from initial target) 4	Projected Target of Lives Saved for following calendar to try to finish commitment 4
	New Lives Lost (lives lost – actual lives saved) 0

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Zero Falls with injury for our patients View Commitment

Zero Falls with injury for our patients – Update – 01.29.18 View Update

Parrish Medical Center

Zero Falls with injury for our patients – Update – 01.29.18

Contact Info

Name: edwin loftin

Phone: 321-268-6120

Email: edwin.loftin@parrishmed.com

Position: VP Acute Care/ CNO

Organization Name: Parrish Medical Center

Commitment Details

Commitment Start Date: 08/01/2016

How many hospitals are represented in this commitment?

Last Report
1

Current
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 Update:
- Frequent observation and hourly rounding on the fall risk patient - Review of clinical equipment for function and efficacy as well as development of new process for patient safety when out of bed for fall risk patients - Ancillary staff such as EVS and Dietary have been enlisted for alarms awareness and response to alarms

Your commitment aligns with APSS
Challenge 14 - Falls and Fall Prevention

Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
- The development of an all or nothing approach for patients at risk was established and a fall bundle created. - Each patient at risk will be visually identified using yellow non-skid socks, door magnets, and wristbands in addition to bed alarms and chair alarms. - Hands on or within interventional range' for out Of bed activity. - A new computer based learning module was created for both clinical and non-clinical staff with an accountability statement - Support for additional initiatives such as care team rounds, early ambulation, hourly rounding Interdisciplinary post fall conference at bedside.

Impact Details

Initial Commitment	Commitment Update	Project Next Year
Lives Lost 0	Lives Lost 0	Lives Lost: 0
Lives Spared Harm Target 0	Actual Lives Spared Harm in last 12 months 16	Lives Spared Harm Target for following calendar year 16
Lives Saved Target 0	Actual Lives Saved in last 12 months (might differ from initial target) 16	Projected Target of Lives Saved for following calendar to try to finish commitment 16
	New Lives Lost (lives lost – actual lives saved) 0

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Critical Congenital Heart Disease Screening in Newborns View Commitment

Critical Congenital Heart Disease Screening in Newborns – Update – 01.29.18 View Update

Parrish Medical Center

Critical Congenital Heart Disease Screening in Newborns – Update – 01.29.18

Contact Info

Name: edwin loftin

Phone: 321-268-6120

Email: edwin.loftin@parrishmed.com

Position: VP Acute Care/ CNO

Organization Name: Parrish Medical Center

Commitment Details

Commitment Start Date: 09/01/2012

How many hospitals are represented in this commitment?

Last Report
1

Current
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 Update:
- Screening program continues for all newborns delivered at Parrish Medical Center - New query to be added to CCHD intervention to streamline data collection

Your commitment aligns with APSS
Challenge 7 - Neonatal Safety

Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
We continue to screen all newborns and follow the CCHD algorithm from the American Academy of Pediatrics, and notify pediatricians of all positive screens for further treatment. (We were doing this before it was required by the state, as we previously discussed, we are often early adopters of patient safety initiatives.)

Impact Details

Initial Commitment	Commitment Update	Project Next Year
Lives Lost 0	Lives Lost 0	Lives Lost: 0
Lives Spared Harm Target 0	Actual Lives Spared Harm in last 12 months 2	Lives Spared Harm Target for following calendar year 2
Lives Saved Target 0	Actual Lives Saved in last 12 months (might differ from initial target) 2	Projected Target of Lives Saved for following calendar to try to finish commitment 2
	New Lives Lost (lives lost – actual lives saved) 0

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VAE/IVAC - Ventilator Associated Event w/infection View Commitment

VAE/IVAC – Ventilator Associated Event w/infection - Update - 01.29.18 View Update

Parrish Medical Center

VAE/IVAC – Ventilator Associated Event w/infection – Update – 01.29.18

Contact Info

Name: edwin loftin

Phone: 321-268-6120

Email: edwin.loftin@parrishmed.com

Position: VP Acute Care/ CNO

Organization Name: Parrish Medical Center

Commitment Details

Commitment Start Date: 01/01/2015

How many hospitals are represented in this commitment?

Last Report
1

Current
1

Action Plan:
Continue monitoring sputum cultures for events, maintain EBP bundles, perform daily needs assessment for devices.

Commitment Update:
- Continue monitoring of PEEP/Fi02 for events

Your commitment aligns with APSS
Challenge 2D - Ventilator-Associated Pneumonia (VAP)

Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
Daily oral care and daily check-list.

Impact Details

Initial Commitment	Commitment Update	Project Next Year
Lives Lost 0	Lives Lost 0	Lives Lost: 0
Lives Spared Harm Target 0	Actual Lives Spared Harm in last 12 months 6	Lives Spared Harm Target for following calendar year 6
Lives Saved Target 0	Actual Lives Saved in last 12 months (might differ from initial target) 6	Projected Target of Lives Saved for following calendar to try to finish commitment 6
	New Lives Lost (lives lost – actual lives saved) 0

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Distribution of "Baby Boxes" to decrease the incidence of co-bedding and SIDs deaths View Commitment

Distribution of “Baby Boxes” to decrease the incidence of co-bedding and SIDs deaths – Update – 01.29.18 View Update

Parrish Medical Center

Distribution of “Baby Boxes” to decrease the incidence of co-bedding and SIDs deaths – Update – 01.29.18

Contact Info

Name: edwin loftin

Phone: 321-268-6120

Email: edwin.loftin@parrishmed.com

Position: VP Acute Care/ CNO

Organization Name: Parrish Medical Center

Commitment Details

Commitment Start Date: 05/23/2016

How many hospitals are represented in this commitment?

Last Report
1

Current
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 Update:
- 800 new Baby Boxes have been donated by the Jess Parrish Foundation for distribution in 2017 & 2018 - Investigation continues for additional funding sources for future purchases of Baby Boxes and supplies - County wide statistics continue to be monitored for effect on SIDS deaths

Your commitment aligns with APSS
Other

Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
We will continue distributing baby boxes to all families who deliver at Parrish Medical Center because it is the right thing to do to provide a safe place for all babies to sleep. However as always the main focus is always on education, educating families about safe sleep and the avoidance of co-bedding, the major contributor for SIDS death, is even more important than the boxes alone.

Impact Details

Initial Commitment	Commitment Update	Project Next Year
Lives Lost 0	Lives Lost 0	Lives Lost: 0
Lives Spared Harm Target 0	Actual Lives Spared Harm in last 12 months 4.28	Lives Spared Harm Target for following calendar year 4.28
Lives Saved Target 0	Actual Lives Saved in last 12 months (might differ from initial target) 4.28	Projected Target of Lives Saved for following calendar to try to finish commitment 4.28
	New Lives Lost (lives lost – actual lives saved) 0

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SSI - Surgical Site Infection for COLO and HYST procedures View Commitment

SSI – Surgical Site Infection for COLO and HYST procedures – Update – 01.29.18 View Update

Parrish Medical Center

SSI – Surgical Site Infection for COLO and HYST procedures – Update – 01.29.18

Contact Info

Name: edwin loftin

Phone: 321-268-6120

Email: edwin.loftin@parrishmed.com

Position: VP Acute Care/ CNO

Organization Name: Parrish Medical Center

Commitment Details

Commitment Start Date: 01/01/2015

How many hospitals are represented in this commitment?

Last Report
1

Current
1

Action Plan:
Continue monitoring site cultures, site assessments and post d/c surveillance for events, maintain EBP bundles.

Commitment Update:
- Continue surveillance for: ED visits, Readmissions within 30 days of procedure, radiologic exam positive for infection/abscess and/or positive wound cultures at the surgical site - Verify use of ASHP guidelines for pre-operative antibiotics - Perform assessments of OR pressures and OR traffic

Your commitment aligns with APSS
Challenge 2C - Surgical Site Infections (SSI)

Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
Best practices learned: Use of CHG for skin prep in OR, hair clipping, postoperative normothermia, adequate glucose control, VTE prophylaxis. Minimize traffic in/out of rooms while being set up and in progress, monitor temperature, humidity, and pressures, minimize IUSS.

Impact Details

Initial Commitment	Commitment Update	Project Next Year
Lives Lost 0	Lives Lost 0	Lives Lost: 0
Lives Spared Harm Target 0	Actual Lives Spared Harm in last 12 months 2	Lives Spared Harm Target for following calendar year 2
Lives Saved Target 0	Actual Lives Saved in last 12 months (might differ from initial target) 2	Projected Target of Lives Saved for following calendar to try to finish commitment 2
	New Lives Lost (lives lost – actual lives saved) 0

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Sepsis View Commitment

Sepsis – Update – 01.29.18 View Update

Parrish Medical Center

Sepsis – Update – 01.29.18

Contact Info

Name: edwin loftin

Phone: 321-268-6120

Email: edwin.loftin@parrishmed.com

Position: VP Acute Care/ CNO

Organization Name: Parrish Medical Center

Commitment Details

Commitment Start Date: 08/01/2016

How many hospitals are represented in this commitment?

Last Report
1

Current
1

Action Plan:
Develop multidisciplinary team to evaluate evidence based practice of Sepsis bundle.

Commitment Update:
- Sepsis committee assesses opportunities, identifies and implements solutions and gathers/reports data pertaining to this APSS - Conducts weekly safety meetings to discuss variances in the sepsis protocol - Sepsis committee meets monthly to fulfill the obligations to the sepsis population

Your commitment aligns with APSS
Challenge 9 - Early Detection and Treatment Of Sepsis

Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
- Board level involvement in the sepsis program - Established Interdisciplinary Sepsis Committee - Sepsis Dashboard in place - Critical Assessment Team in place for sepsis patients - Sepsis screening tool incorporated into EHR / pulls automated screening information - Alerts in place for “high” screening - Separate sepsis profile for continuous monitoring and early detection based on changes in patient’s clinical status - Workflow specific to level of alert - Sepsis order sets in place/ monitoring for compliance in their use - Peer review process in place for outliers

Impact Details

Initial Commitment	Commitment Update	Project Next Year
Lives Lost 0	Lives Lost 0	Lives Lost: 0
Lives Spared Harm Target 0	Actual Lives Spared Harm in last 12 months 19	Lives Spared Harm Target for following calendar year 19
Lives Saved Target 0	Actual Lives Saved in last 12 months (might differ from initial target) 19	Projected Target of Lives Saved for following calendar to try to finish commitment 19
	New Lives Lost (lives lost – actual lives saved) 0

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Antimicrobial Stewardship View Commitment

Antimicrobial Stewardship – Update – 01.29.18 View Update

Parrish Medical Center

Antimicrobial Stewardship – Update – 01.29.18

Contact Info

Name: edwin loftin

Phone: 321-268-6120

Email: edwin.loftin@parrishmed.com

Position: VP Acute Care/ CNO

Organization Name: Parrish Medical Center

Commitment Details

Commitment Start Date: 07/19/2016

How many hospitals are represented in this commitment?

Last Report
1

Current
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 Update:
- 48 hour antibiotic timeout

Your commitment aligns with APSS
Challenge 3B - Antimicrobial Stewardship – The Role of Pharmacy and the Microbiology Lab in Patient Safety

Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
1. Multidisciplinary Team a. Medicine including ID, Pharmacy including ID, Clinical Laboratory, Nursing, IT 2. CPOE w CDS 3. Order sets/Protocols 4. Pharmacy a. All orders reviewed b. Interventions: 48hr time out, IV/PO, Dose optimization, Dose adjustments, Automatic stop orders 5. Microbiology a. Antibiogram twice yearly b. Rapid Diagnostics i. PCR, Molecular DNA Testing c. Procalcitonin d. Selective reporting of susceptibilities of antimicrobials 6. Multifaceted Implementation Strategy a. Restrictive, Prospective audit, Concurrent monitoring 7. Education

Impact Details

Initial Commitment	Commitment Update	Project Next Year
Lives Lost 0	Lives Lost 0	Lives Lost: 0
Lives Spared Harm Target 0	Actual Lives Spared Harm in last 12 months 1	Lives Spared Harm Target for following calendar year 1
Lives Saved Target 0	Actual Lives Saved in last 12 months (might differ from initial target) 1	Projected Target of Lives Saved for following calendar to try to finish commitment 1
	New Lives Lost (lives lost – actual lives saved) 0

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LAB ID event for hospital onset MRSA bloodstream infection and Clostridium difficile infection View Commitment

LAB ID event for hospital onset MRSA bloodstream infection and Clostridium difficile infection – Update – 01.29.18 View Update

Parrish Medical Center

LAB ID event for hospital onset MRSA bloodstream infection and Clostridium difficile infection – Update – 01.29.18

Contact Info

Name: edwin loftin

Phone: 321-268-6120

Email: edwin.loftin@parrishmed.com

Position: VP Acute Care/ CNO

Organization Name: Parrish Medical Center

Commitment Details

Commitment Start Date: 01/01/2015

How many hospitals are represented in this commitment?

Last Report
1

Current
1

Action Plan:
Continue monitoring lab ID events, maintain EBP bundles.

Commitment Update:
- Educate family members on infections - Educate on appropriate testing - Develop and implement a testing algorithm

Your commitment aligns with APSS
Challenge 2E - Clostridium Difficile Infection (CDI)

Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
Best practices learned: Implementation of antimicrobial stewardship program, institution of empiric precautions of placing patients on Contact Precautions at onset of diarrhea, education and re-education of cleaning and disinfection of patient care equipment, Education of timely collection of loose stool, lab rejection of formed stool, and weekly report outs of hospital acquired infections.

Impact Details

Initial Commitment	Commitment Update	Project Next Year
Lives Lost 0	Lives Lost 0	Lives Lost: 0
Lives Spared Harm Target 0	Actual Lives Spared Harm in last 12 months 1.9	Lives Spared Harm Target for following calendar year 1.9
Lives Saved Target 0	Actual Lives Saved in last 12 months (might differ from initial target) 1.9	Projected Target of Lives Saved for following calendar to try to finish commitment 01.9
	New Lives Lost (lives lost – actual lives saved) 0

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CLABSI-Central Line Associated Bloodstream Infection View Commitment

CLABSI-Central Line Associated Bloodstream Infection – Update – 01.29.18 View Update

Parrish Medical Center

CLABSI-Central Line Associated Bloodstream Infection – Update – 01.29.18

Contact Info

Name: edwin loftin

Phone: 321-268-6120

Email: edwin.loftin@parrishmed.com

Position: VP Acute Care/ CNO

Organization Name: Parrish Medical Center

Commitment Details

Commitment Start Date: 01/01/2015

How many hospitals are represented in this commitment?

Last Report
1

Current
1

Action Plan:
Continue monitoring blood cultures for events, maintain EBP bundles, perform daily needs assessment for devices.

Commitment Update:
- Eliminate unnecessary blood draws from lines. - Perform RCS on all CLABSI's - Add insertion checklist to EMR - Document tubing changes

Your commitment aligns with APSS
Challenge 2F - Central Line Associated Blood Stream Infections (CLABSI)

Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
Best practices learned: Education for physicians, nurses, and other licensed practitioners, implementing blood draws from line by physician order only, complete and document an insertion checklist.

Impact Details

Initial Commitment	Commitment Update	Project Next Year
Lives Lost 0	Lives Lost 0	Lives Lost: 0
Lives Spared Harm Target 0	Actual Lives Spared Harm in last 12 months 1	Lives Spared Harm Target for following calendar year 1
Lives Saved Target 0	Actual Lives Saved in last 12 months (might differ from initial target) 1	Projected Target of Lives Saved for following calendar to try to finish commitment 1
	New Lives Lost (lives lost – actual lives saved) 0

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CAUTI-Indwelling Catheter Associated Urinary Tract Infection View Commitment

CAUTI-Indwelling Catheter Associated Urinary Tract Infection – Update – 01.29.18 View Update

Parrish Medical Center

CAUTI-Indwelling Catheter Associated Urinary Tract Infection – Update – 01.29.18

Contact Info

Name: edwin loftin

Phone: 321-268-6120

Email: edwin.loftin@parrishmed.com

Position: VP Acute Care/ CNO

Organization Name: Parrish Medical Center

Commitment Details

Commitment Start Date: 01/01/2015

How many hospitals are represented in this commitment?

Last Report
1

Current
1

Action Plan:
Continue monitoring urine cultures for events, maintain EBP bundles, perform daily needs assessment for devices.

Commitment Update:
Implemented: - Nurse driven protocol - Assessment/education on alternatives to indwelling urinary catheters

Your commitment aligns with APSS
Challenge 2B - Catheter-Associated Urinary Tract Infections (CAUTI)

Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
CAUTI Best practices learned: Best practices currently in place include inserting catheters only for appropriate indications, only properly trained persons insert and maintain catheters, and performing aseptic insertion. We learned that implementing a nurse driven protocol for removal of indwelling foley catheters will be beneficial.

Impact Details

Initial Commitment	Commitment Update	Project Next Year
Lives Lost 0	Lives Lost 0	Lives Lost: 0
Lives Spared Harm Target 0	Actual Lives Spared Harm in last 12 months 1	Lives Spared Harm Target for following calendar year 1
Lives Saved Target 0	Actual Lives Saved in last 12 months (might differ from initial target) 1	Projected Target of Lives Saved for following calendar to try to finish commitment 1
	New Lives Lost (lives lost – actual lives saved) 0

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UC Irvine Health

Preventing CDI View Commitment

Preventing SSI-Colon Surgery View Commitment

Preventing SSI-Abdominal Hysterectomy View Commitment

Preventing CAUTI View Commitment

Improving Medication Harm Errors View Commitment

Antimicrobial Stewardship View Commitment

Preventing Insulin-Induced Hypoglycemia View Commitment

Preventing Failure to Rescue View Commitment

Improvement of Patient Blood Management View Commitment

APSS #9 Preventing Sepsis View Commitment

APSS #10 Ensuring Optimal Resuscitation View Commitment

Creating a Culture of Safety View Commitment

Reducing the Risk of Central Line-associated Bloodstream Infection View Commitment

Changhua Christian Hospital

Changhua

Failure to detect critical congenital heart disease (CCHD) View Commitment

Airway Safety View Commitment

Healthcare-associated Infections (HAIs) View Commitment

Creating a Culture of Safety View Commitment

Hand-off Communications View Commitment

University of Vermont Medical Center

2E-HAI-Clostridium Difficile View Commitment

Targeting Zero: Eliminating/Reducing Central Line Associated Blood Stream Infections View Commitment

Culture of Safety View Commitment

Hand-off Communication Improvement View Commitment

Alignment of Supply Chain and Information Systems Contracting and Supplier Management Processes to Ensure Interoperability of Medical Devices and Clinical Software View Commitment

Secretaría de Salud

Hidalgo

Planificación de atención colaborativa View Commitment

The enhancement of adverse events report in the Automated Health Incident Registry System (SIRAIS) platform. View Commitment

Avoiding maternal morbi-mortality. View Commitment

CIRUGIA SEGURA View Commitment

Hospital-acquired Pneumonia Prevention Initiative (HAPPI): Prevention of non-ventilator Pneumonia View Commitment

El Médico en tu Casa: Home health care in vulnerable population View Commitment

Scottish Patient Safety Programme (SPSP)

Scotland

The Scottish Patient Safety Programme (SPSP): Mental Health View Commitment

The Scottish Patient Safety Programme (SPSP): Medicines View Commitment

The Scottish Patient Safety Programme (SPSP): Maternity and Children View Commitment

The Scottish Patient Safety Programme (SPSP): Healthcare-acquired Infections View Commitment

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

Children's Hospitals' Solutions for Patient Safety

Eliminating Serious Harm in Children's Hospitals - Obstetrical Adverse Events View Commitment

Eliminating Serious Harm in Children's Hospitals - Readmissions View Commitment

Eliminating Serious Harm in Children's Hospitals - Falls View Commitment

Eliminating Serious Harm in Children's Hospitals - VAP View Commitment

Eliminating Serious Harm in Children's Hospitals - Pressure Ulcers View Commitment

Eliminating Serious Harm in Children's Hospitals - CLABSI View Commitment

Eliminating Serious Harm in Children's Hospitals - SSI View Commitment

Eliminating Serious Harm in Children's Hospitals - CAUTI View Commitment

Eliminating Serious Harm in Children's Hospitals View Commitment

Eliminating Serious Harm in Children’s Hospitals - CAUTI - Update - 12.03.16 View Update

Tri-City Medical Center

California

3. Improve the Agency for Healthcare Research and Quality (AHRQ) Culure of Safety scores compared to the 2016 survey data. View Commitment

2. Reducing falls on the inpatient nursing units at Tri-City Medical Center View Commitment

1. To maintain our Neonatal Intensive Care Unit (NICU) free of any Central Line Associated Bloodstream Infections (CLABSI). 2. To reduce falls on our inpatient care units (1 North, Pavilion, Telemetry and ICU) by 20% compared to FY16 data. 3. Improve the Agency for Healthcare Research and Quality (AHRQ) Culture of Safety scores compared to the 2016 survey data. View Commitment

Sharp HealthCare

Reducing Medication Errors View Commitment

Zero Suicides: Inpatient and within 72 hours of Discharge View Commitment

Culture of Safety; Eliminate wrong patient, side and site surgery and procedures View Commitment

Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suarez

Ciudad de México

Reducing Hospital Associated Infections caused by Hand Hygiene in Patients with Nervous System Disease View Commitment

Consultoría en Enfermería View Commitment

Consultoría en Enfermería – Update – 01.29.18 View Update

Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suarez

Consultoría en Enfermería – Update – 01.29.18

Contact Info

Name: MRN. Rocío Valdez Labastida

Phone: (55) 56063822 ext 1062, 1098

Email: rvaldez@innn.edu.mx

Position: Subdirectora de Enfermería, Maestra en Rehabilitación Neurológica y con Licenciatura en Enferemría

Organization Name: Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suarez

Commitment Details

Commitment Start Date: 01/01/2017

How many hospitals are represented in this commitment?

Last Report
1

Current
1

Action Plan:
Formar y capacitar profesionales de enfermería como consultoras Implementar el modelo de Consultoría en Enfermería Difundir el modelo de Consultoría en Enfermería Desarrollar e implementar indicadores que permitan medir el impacto y generar acciones de mejora Establecer una metodología de evaluación

Commitment Update:
El Instituto, continuo con el modelo de Consultoría en Enfermería Neurológica, en cuidados paliativos y en heridas y estomas cumplió en reducir el número de ingresos hospitalarios por complicaciones por mal cuidado en el hogar, prolongó la vida y su calidad, impactando en el proceso de atención y en la planificación del egreso del paciente neurológico a su domicilio. El resultado fue otorgar 688 atenciones a pacientes que acudieron al INNN, lo que representó un aumento 171 atenciones que, en el 2016, lo que evito sus reingresos. Durante el año 2017, se recibió la donación de simuladores anatómicos adulto y geriátrico, monitor de signos vitales, aditamentos de exploración neurológica, espacio físico para crear el Centro de Instrucción de Enfermería Especializada (CIEE). Dio inicio a la evaluación del impacto de la consultoría en enfermaría, con el fin de realizar acciones de mejora que repercuta en el cuidado del paciente neurológico.

Your commitment aligns with APSS
Consultoria en Enfermería

Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
El desarrollo de habilidades y destrezas del cuidador principal, el apoyo moral, económico por parte de la comunidad hospitalaria al compromiso adicional realizado por cada uno de los integrantes de la familia. Por último, la integración del paciente a que sea productivo y del autocuidado al reintegrarse a la sociedad.

Impact Details

Initial Commitment	Commitment Update	Project Next Year
Lives Lost	Lives Lost	Lives Lost: 0
Lives Spared Harm Target	Actual Lives Spared Harm in last 12 months 688	Lives Spared Harm Target for following calendar year 690
Lives Saved Target	Actual Lives Saved in last 12 months (might differ from initial target) 15	Projected Target of Lives Saved for following calendar to try to finish commitment 20
	New Lives Lost (lives lost – actual lives saved) 0

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Desarrollar un modelo de cultura de la seguridad y calidad en INNN durante el periodo 2017 a 2018 View Commitment

Desarrollar un modelo de cultura de la seguridad y calidad en INNN durante el periodo 2017 a 2018 – Update – 01.29.18 View Update

Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suarez

Desarrollar un modelo de cultura de la seguridad y calidad en INNN durante el periodo 2017 a 2018 – Update – 01.29.18

Contact Info

Name: Roberto Galán

Phone: (55) 56063822 ext. 1012

Email: rgalan@innn.edu.mx

Position: Subdirector de Servicios Auxiliares de Diagnóstico y Tratamiento, Medico Cirujano

Organization Name: Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suarez

Commitment Details

Commitment Start Date: 01/01/2017

How many hospitals are represented in this commitment?

Last Report
1

Current
1

Action Plan:
Elaborar el plan para la presentación del modelo de seguridad y calidad para difundirlo a todo el personal de la rama médica y paramédica adscrito al Instituto. Generar carteles, trípticos, videos que den a conocer el modelo a todo el personal de la rama médica y paramédica adscrito al Instituto. Sesiones educativas de coaching quincenales con el fin de reforzar y desarrollar el modelo de seguridad y calidad en el paciente a todo el personal adscrito al Instituto. Realizar rastreos mensuales en todos los departamentos del instituto para evaluar la aplicación del modelo se seguridad y calidad. Generar las sesiones informativas basada en los resultados de los rastreos y avances alcanzados en las diferentes áreas del instituto. Establecer indicadores que permitan medir el impacto y permitan generar acciones de mejora.

Commitment Update:
Durante el año del 2017, se desarrolló el Plan de Modelo de Cultura de la Seguridad y Calidad, que permitió establecer políticas con un enfoque proactivo, sistemático y multidisciplinario. Como resultado se cuenta con un expediente clínico electrónico (ECE) apegado a las normas mexicanas, cuidando la privacidad y confidencialidad del paciente, en donde los profesionales de la salud** tienen acceso seguro al ECE, lo que permite la trazabilidad del paciente y usuario del ECE. Dentro del ECE, se registra y validar cada una de las notas médicas con su firma electrónica, permite aplicar las metas internacionales, el registro de alergias del paciente, continuidad de la atención del paciente, identificar la dieta y medicamentos prescritos por el médico tratante bajo en unidosis, registro de la lista de verificación de cirugía segura, consentimientos informados por procedimiento invasivo, entre otros. Se ha observado incremento en la cultura del reporte de eventos adversos, se dio inicio al análisis Causa- raíz de eventos centinelas, **Profesionales de la salud: médicos, enfermeras y personal técnico (radiológico, inhalo terapista, rehabilitación, químico laboratorista, entre otros).

Your commitment aligns with APSS
Challenge 1 - Creating a Culture of Safety

Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
El Programa de Análisis de Cuasifallas, Eventos Adversos y Eventos Centinela ha permitido fomentar la cultura del reporte de los mismos y el análisis proactivo con miras a reducir la recurrencia y las complicaciones. El análisis Causa- Raíz ha permitido aprender de los errores y verlos como una oportunidad

Impact Details

Initial Commitment	Commitment Update	Project Next Year
Lives Lost	Lives Lost	Lives Lost: 0
Lives Spared Harm Target	Actual Lives Spared Harm in last 12 months 3114	Lives Spared Harm Target for following calendar year 3091
Lives Saved Target	Actual Lives Saved in last 12 months (might differ from initial target) 73	Projected Target of Lives Saved for following calendar to try to finish commitment 70
	New Lives Lost (lives lost – actual lives saved) 0

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Disminuir las infecciones asociadas al cuidado de la salud en pacientes con padecimientos del sistema nervioso en el INNN a través del lavado de manos en el año 2017 View Commitment

University of Pittsburgh Medical Center

Getting to Zero-Eliminating Preventable Death from VTE View Commitment

Reduce the mortality rate of our patients with Sepsis and Septic Shock View Commitment

Getting to Zero – Eliminating Surgical Site Infections View Commitment

Getting to Zero – Eliminating Surgical Site Infections - Update View Update

University of Pittsburgh Medical Center

Getting to Zero – Eliminating Surgical Site Infections – Update

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?

Last Report
0

Current
0

Action Plan:

Commitment Update:
Our plan consisted of six areas of focus including standardizing preoperative bathing with a chlorhexidine (CHG) product, proper skin preparation utilizing a CHG product for skin antisepsis prior to surgery, standardized postoperative wound care, uniform and comprehensive discharge instructions, limiting operating room (OR) traffic and controlled OR attire and reducing or eliminating Immediate-Use Steam Sterilization. Through the System Infection Prevention & Control Group we have evaluated pre-operative bathing and revised the instructions sheets provided to the patient to use at home. CHG cloths are used in the pre-operative areas to decrease bio-burden on the patient’s skin especially concentrating on the operative site. Post-operative wound care is being standardized in collaboration with surgeon colleagues. Standard discharge instructions for wound care have been developed and deployed. Strict OR traffic and attire guidelines have been developed to reduce contamination risk. Strategic planning of breaks and lunches limits the frequency of staff entering and leaving the OR suite. All facilities are working to decrease and/or eliminate their use of Immediate-Use Steam Sterilization. Increasing the supply of frequently used surgical instruments has helped to decrease the need for immediate–use sterilization. These practices have led to the decrease in the median SSI SIR from 0.676 to 0.539 which exceeded our goal of 0.60.

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

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
Lives Saved Target	Actual Lives Saved in last 12 months (might differ from initial target)	Projected Target of Lives Saved for following calendar to try to finish commitment
	New Lives Lost (lives lost – actual lives saved)

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Getting to Zero – Eliminating Central Line Associated Blood Stream Infections View Commitment

Getting to Zero – Eliminating Central Line Associated Blood Stream Infections - Update - 2014 View Update

Reducing Failed Transitions View Commitment

Reducing Failed Transitions - Update - 2015 View 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?

Last Report
0

Current
13

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	Lives Lost	Lives Lost:
Lives Spared Harm Target	Actual Lives Spared Harm in last 12 months	Lives Spared Harm Target for following calendar year
Lives Saved Target	Actual Lives Saved in last 12 months (might differ from initial target)	Projected Target of Lives Saved for following calendar to try to finish commitment
	New Lives Lost (lives lost – actual lives saved)

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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

The Patient Blood Management Program of UPMC (PBM) – Improving the Quality and Safety of Patient Care, while reducing the cost per capita of healthcare - Update - 2015 View Update

University of Pittsburgh Medical Center

The Patient Blood Management Program of UPMC (PBM) – Improving the Quality and Safety of Patient Care, while reducing the cost per capita of healthcare – Update – 2015

Contact Info

Name: Mary Kay Wisniewski

Phone: (412) 802-8066

Email: wisniewskimk@upmc.edu

Position: UPMC Patient Blood Management Program Coordinator

Organization Name: University of Pittsburgh Medical Center

Commitment Details

Commitment Start Date: 03/13/2014

How many hospitals are represented in this commitment?

Last Report
0

Current
1

Action Plan:

Commitment Update:
2015 PBM program outcomes are directly related to multidisciplinary collaboration and commitment. -Reduced non-evidence based transfusions by 12% (exceeding milestone goal of 10%) -Reduced blood product waste, 1) decreased red blood cell units wasted by 41% and 2) decreased platelet wasted units by 67%. The blood waste prevention initiative has resulted in a $183K cost avoidance. -Reduced volume of purchased products, 1) RBC 7% decrease, 2) plasma 2.7% decrease, and 3) platelets 8.0% decreased. This reduction in purchased blood products has resulted in a $1.5M cost avoidance.

Your commitment aligns with APSS
Challenge 5 - Anemia and Transfusions

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	Lives Lost	Lives Lost:
Lives Spared Harm Target	Actual Lives Spared Harm in last 12 months	Lives Spared Harm Target for following calendar year
Lives Saved Target	Actual Lives Saved in last 12 months (might differ from initial target)	Projected Target of Lives Saved for following calendar to try to finish commitment
	New Lives Lost (lives lost – actual lives saved)

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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. View Commitment

Emergency Physician Airway Management Training and Standardization of Guidelines View Commitment

Best Code Airway Management View Commitment

Mayo Clinic, Florida

The Blue Angel Standard View Commitment

Minimize transfusion by eliminating pre-operative anemia in patients presenting to the OR for elective surgery. View Commitment

Minimize transfusion by eliminating pre-operative anemia in patients presenting to the OR for elective surgery - Update View Update

Mayo Clinic Florida

Minimize transfusion by eliminating pre-operative anemia in patients presenting to the OR for elective surgery – Update

Contact Info

Name: Klaus Torp

Phone: 904-956-3328

Email: torp.klaus@mayo.edu

Position: Assistant Professor of Anesthesiology

Organization Name: Mayo Clinic Florida

Commitment Details

Commitment Start Date: 01/03/2014

How many hospitals are represented in this commitment?

Last Report
1

Current
1

Action Plan:
Pre-operative anemia is a major risk factor for perioperative blood transfusion. Often the patient's hemoglobin is not known until the patient is scheduled for surgery and goes through the pre-operative workup, which may occur too close to the surgical date to correct anemia effectively. Knowing the Hgb value at the time of the surgical office visit would help in directing the patient to either the regular preoperative pathway or to an anemia management program.

Commitment Update:
A Hgb screening tool has been identified and approved by the laboratory director. An electronic interface has been created to report the Hgb values into the medical record. Training of the personnel in the correct use of the Hgb spot check device has been completed. An laboratory test algorithm in case of low Hgb spot check values has been created. An anemia management program, using EPO injections for those patients with anemia of chronic disease has been created and approved for a pilot project.

Your commitment aligns with APSS
Challenge 5 - Anemia and Transfusions

Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
Meeting with the appropriate stakeholders is important like the laboratory, hematology, surgical service, ambulatory infusion center and billing department in order not to miss important details of the project. Nothing is ever simple. The biggest issue is to assemble the right people with the right knowledge and motivation who are ready to make a change. Everyone has part of the answer, but putting it all together is time consuming for people who have additional clinical responsibilities. This project involved two components: 1) Identification of anemic patients early, before they are scheduled for surgery and 2) Create an anemia management program that would work for most patients using existing resources.

Impact Details

Initial Commitment	Commitment Update	Project Next Year
Lives Lost 0	Lives Lost 0	Lives Lost: 0
Lives Spared Harm Target 0	Actual Lives Spared Harm in last 12 months 0	Lives Spared Harm Target for following calendar year 0
Lives Saved Target 0	Actual Lives Saved in last 12 months (might differ from initial target) 0	Projected Target of Lives Saved for following calendar to try to finish commitment 60
	New Lives Lost (lives lost – actual lives saved) 0

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Sepsis and Shock Response Team (SSRT): A Multidisciplinary Approach to Bundle Adherence and Patient Safety View Commitment

Hospital Quality Institute (HQI)

Reduce death from sepsis View Commitment

Reduce death from sepsis – Update – 01.25.18 View Update

Hospital Quality Institute (HQI)

Reduce death from sepsis – Update – 01.25.18

Contact Info

Name: Julianne Morath

Phone: (916) 552-7600

Email: info@hqinstitute.org

Position: President/CEO

Organization Name: Hospital Quality Institute (HQI)

Commitment Details

Commitment Start Date: 01/01/2015

How many hospitals are represented in this commitment?

Last Report
400

Current
400

Action Plan:
1. Provide peer-to-peer learning through learning opportunities/activities and mentor hospitals 2. Distribute evidence- based guidelines and playbooks 3. Provide ongoing performance feedback 4. Provide sepsis simulation trainings 5. Support and work with Process Improvement team

Commitment Update:
1. 2017 peer-peer sepsis learning opportunities: a. Three in-person peer-peer learning events hosting 150 attendees representing 100 hospitals b. Access to five national sepsis expert webinars c. HQI annual conference sepsis focused breakout sessions and posters : Over 400 attendees from 200+ hospitals 2. Sepsis Clinical Field Guide disseminated via HSAG HIIN, HQI Sepsis Infographic distributed via websites and mailing lists 3. Unblinded hospital variation data provided to Regional Association Boards 4. Ongoing individualized support to hospitals 5. Roundtable held and proceedings to be published 1Q2018.

Your commitment aligns with APSS
Challenge 9 - Early Detection and Treatment Of Sepsis

Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
With the 2004 original SSC campaign, Hospital X focused on intensive care (ICU) response to sepsis with high usage of protocols. Early mortality rates dropped from 40% to 28% as a result. To obtain further gains, the leadership recognized it was important to convey that sepsis was not an ICU problem but a hospital problem. Existing protocols were split into high, medium, and low intensity to match levels of care on the nursing units so that patients on all nursing units received recognition of sepsis, initial treatment, and were transferred to higher acuity as needed. In addition, Hospital X added a dedicated sepsis nurse and triage in the ED to recognize patients early and begin treatment. Resulting in $7,000 cost per case and 14 percent savings overall, even after accounting for additional FTE for the dedicated sepsis nurse. The value of the sepsis nurse eliminated grey area of patients waiting in the ED for an available ICU bed. This positively impacted ED flow and ICU availability, in addition to the patient benefit from prompt treatment. The nurse coverage started with 12 hours daily and then expanded to 24-hour coverage. The nurse also followed patients for 24-36 hours to relieve ICUs. Initially the sepsis nurse’s role was to be an extra hand in ICUs with a high census. It evolved to be a dedicated sepsis responsibility. Health System X has adopted some variation of the dedicated nurse in all hospitals. For training, the sepsis nurses are drawn from those who have a minimum of two years’ experience in critical care and rapid response (RRT). Initially, the sepsis nurse was used as a flexible resource to bolster lean staffing in critical care or other areas. At Hospital X, after recognizing the positive value of the resource, the sepsis nurses can no longer be pulled. From all efforts, Hospital X’s sepsis mortality dropped from 25 percent in 2002 to 5-6 percent today. The sepsis nurses across Health System X are currently working to create standardized performance among all hospitals. This work involves reducing from 33 separate order sets to two order sets, containing exact workflow. At Hospital Y, the sepsis nurse completes sepsis consults with staff, evaluates sepsis screens, and consults with other nurses. The sepsis nurse sees on average 200-230 patients per month but some see well over 300 monthly. Hospital Y is staffed with one sepsis nurse plus one RRT nurse. For hospitals employing this resource, Health System X has tried multiple phases and found an evolutionary process that works by building the sepsis nurse into the RRT team at first and then separating the resource as demand and value builds. The organization’s guide to determine how sepsis nurses are deployed is based on the volume of annual sepsis cases. For a hospital with 1500 cases, a dedicated sepsis nurse utilized covering day and some eve/weekend shifts. The number of cases is measured initially by examining DRG cases. Ultimately, the sepsis nurse case volume is recommended to be measured by how many times the protocol is activated because that is where the work is. The order set must be activated to signal the need for the sepsis nurse. No activation, no nurse.

Impact Details

Initial Commitment	Commitment Update	Project Next Year
Lives Lost 0	Lives Lost 0	Lives Lost: 0
Lives Spared Harm Target 0	Actual Lives Spared Harm in last 12 months 0	Lives Spared Harm Target for following calendar year 0
Lives Saved Target 0	Actual Lives Saved in last 12 months (might differ from initial target) 4064	Projected Target of Lives Saved for following calendar to try to finish commitment 4259
	New Lives Lost (lives lost – actual lives saved) 0

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Eliminate preventable mortality and morbidity in maternity care View Commitment

Eliminate preventable mortality and morbidity in maternity care – Update – 01.25.18 View Update

Hospital Quality Institute (HQI)

Eliminate preventable mortality and morbidity in maternity care – Update – 01.25.18

Contact Info

Name: Julianne Morath

Phone: (916) 552-7600

Email: info@hqinstitute.org

Position: President/CEO

Organization Name: Hospital Quality Institute (HQI)

Commitment Details

Commitment Start Date: 01/01/2015

How many hospitals are represented in this commitment?

Last Report
243

Current
242

Action Plan:
1. Recruit hospitals with maternity services to CMQCC 2. Increase data reporting to CMQCC database: California Maternal Data Center (CMDC) 3. Develop method of data capturing at state level 4. Distribute evidence- based guidelines and playbooks 5. Provide ongoing performance feedback 6. Conduct collaboratives to support hospital and medical staff in change management 7. Develop mentors for hospitals and medical staff

Commitment Update:
Evidence-Based Medicine (EBM) maternal care guidelines and bundles were developed and distributed • April 2016: Deployed Supporting Vaginal Births Toolkit to 243 birthing hospitals and CHPSO’s national network (including OB Hemorrhage, Preeclampsia, EED) • August 2017: Deployed Promoting Optimal NTSV Delivery Rates (PONDR) report to 243 birthing hospitals • Distributed CMQCC toolkits to 243 maternity hospitals • Made SmartCare Award Announcements • Released CalHospital Compare maternal outcome data to hospitals • Continued HQI-CMQCC programming Collaboratives are established and meeting to accelerate maternal improvement. • Participate in monthly maternity collaborative calls with CHCF, CMQCC, IHA, DHCS, PBGH • Member, CMQCC Executive Committee • CMQCC Collaborative – recruiting hospitals for third phase • ACOG Speakers’ Bureau – recruiting hospitals for inaugural year Mentors are available through the ACOG Speakers’ Bureau. Early Elected Deliveries (EED) are continuing to be reduced at an accelerated rate. • There was a 46% reduction in EED seen in HEN 2.0 hospitals (n=124) encompassed the period from October 2015-September 2016. During roughly that same period the Hospital Compare data show a reduction of 51.1% (n=105) vs. CY 2014.

Your commitment aligns with APSS
Challenge 11 - Optimizing Obstetric Safety

Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
HQI’s emphasis on patient safety is rooted in the Institute of Medicine’s landmark report, To Err is Human. We continually draw our foundational research from organizations such as the American College of Obstetricians and Gynecologists (ACOG) and The Joint Commission Patient Safety Journal and releases from PSMF. The learnings from these organizations such as these are used in our research, such as the PONDR report, and shared with hospitals through venues such as the CHPSO Patient Safety Organization safe table or webinars. One of the challenges we have overcome is building a rapport with hospital contacts. Relationships with hospital teams require time and we often find there is turnover. HQI continues to maintain its commitment to disseminating resources with hospitals from within and from our stakeholders, alerting hospitals of communications from external organizations before they become public, and sustaining open lines of communication.

Impact Details

Initial Commitment	Commitment Update	Project Next Year
Lives Lost	Lives Lost	Lives Lost: 0
Lives Spared Harm Target	Actual Lives Spared Harm in last 12 months 14311	Lives Spared Harm Target for following calendar year 14392
Lives Saved Target	Actual Lives Saved in last 12 months (might differ from initial target) 9	Projected Target of Lives Saved for following calendar to try to finish commitment 9
	New Lives Lost (lives lost – actual lives saved) 0

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Aim is to eliminate preventable harm to hospitalized patients View Commitment

Aim is to eliminate preventable harm to hospitalized patients – Update – 01.25.18 View Update

Hospital Quality Institute (HQI)

Aim is to eliminate preventable harm to hospitalized patients – Update – 01.25.18

Contact Info

Name: Julianne Morath, RN, MS, CPPS

Phone: (916) 552-7600

Email: info@hqinstitute.org

Position: President/CEO

Organization Name: Hospital Quality Institute (HQI)

Commitment Details

Commitment Start Date: 01/01/2015

How many hospitals are represented in this commitment?

Last Report
400

Current
400

Action Plan:
1. Continue to support successes and sustain gains 2. Stratify hospitals with greatest opportunities 3. Recruit virtual collaboratives 4. Encourage reporting and provide ongoing feedback 5. Engage senior leadership 6. Provide evidence- based practices 7. Provide peer- to- peer learning through learning opportunities/ activities and mentor hospitals

Commitment Update:
1. Continued to support successes and sustain gains 2. Stratified hospitals with greatest opportunities and assigned mentor 3. Continued conducting virtual collaboratives 4. Encouraged reporting and provided ongoing feedback through HQI improvement forums 5. Engaged senior leadership through HIIN, CMQCC, and quarterly CEO reports 6. Evidence-based practices deployed through website, Clinical Improvement Advisors, studies, and reports 7. Continued peer-to-peer learning through learning opportunities/activities and mentor hospitals, subject matter experts, and patient/family engagement

Your commitment aligns with APSS
Challenge 1 - Creating a Culture of Safety

Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
1. Subject matter experts identified to support improvement teams 2. Developed Khan Academy style High Reliability Modules on Foundations and Clinical Topics of harm available on any web-enabled device by subscription

Impact Details

Initial Commitment	Commitment Update	Project Next Year
Lives Lost	Lives Lost	Lives Lost: 0
Lives Spared Harm Target	Actual Lives Spared Harm in last 12 months 5113	Lives Spared Harm Target for following calendar year 5369
Lives Saved Target	Actual Lives Saved in last 12 months (might differ from initial target) 1614	Projected Target of Lives Saved for following calendar to try to finish commitment 1695
	New Lives Lost (lives lost – actual lives saved) 0

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Instituto Nacional de Cardiología Ignacio Chávez

Medication Errors View Commitment

Patient Safety Culture View Commitment

Instituto Nacional de Ciencias Médicas y Nutricion Salvador Zubirán

Mexico City

Control of Nosocomial Infections View Commitment

Patient Safety Culture and Control of Nosocomial Infections View Commitment

MedStar Health

Serious Safety Events View Commitment

Sepsis View Commitment

Baylor Scott & White Health Care System

Texas

High Risk Surgery Initiative View Commitment

Journey to No Preventable Deaths, No Preventable Injuries and No Preventable Risk. View Commitment

Greystone Park Psychiatric Hospital

Zero harm to patient by 20/20 View Commitment

Taichung Hospital, Ministry of Health and Welfare

Taichung

Challenge 1-Creating a Culture of Safety View Commitment

Smile Train

Safer cleft surgery in the developing world through hospital partnerships and empowerment View Commitment

Safer cleft surgery in the developing world through hospital partnerships and empowerment – Update – 01.03.18 View Update

Smile Train

Safer cleft surgery in the developing world through hospital partnerships and empowerment – Update – 01.03.18

Contact Info

Name: Erin Stieber

Phone: (757) 373-2094

Email: estieber@smiletrain.org

Position: Vice President, Strategic Partnerships

Organization Name: Smile Train

Commitment Details

Commitment Start Date: 01/01/2016

How many hospitals are represented in this commitment?

Last Report
0

Current
13

Action Plan:
Smile Train will be re-signing partnership agreements with 3 hospitals that have been successfully implementing the Smile Train safety and quality protocols in their hospitals for several years. Additionally, over the course of 2016, Smile Train will be engaging with 10 new partner hospitals from around the world, educating them on our safety and quality guidelines and supporting them in their adoption of safe surgery for children with cleft. All patients impacted through this partnership will have their life-changing surgery carefully tracked through Smile Train's innovative online patient medical records database, Smile Train Express, which has been used in more than countries around the world. Additionally, Smile Train will distribute targeted surveys to our Hospital Partners in this Commitment to gather more comprehensive data on how our safety and quality protocols have impacted the safety of the patients being treated as part of this Commitment.

Commitment Update:
Through partnership with Smile Train and adherence to essential safety and quality protocols promulgated by the organization, more than 3,200 patients have received safe, high-quality cleft surgery as part of the Patient Safety Movement Commitment. These developing world hospitals are in 13 different countries across the Americas, Asia and Africa. All life-changing surgeries have been carefully tracked through Smile Train's innovative online patient medical record database, Smile Train Express. 3,200 cleft surgeries were safely provided by the hospitals included in our commitment during the period of the commitment. (Greatly exceeding the 1,500 we had originally anticipated)

Your commitment aligns with APSS
Challenge 1 - Creating a Culture of Safety

Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
The Patient Safety Movement is going amazing work to save patient lives around the world. Smile Train has been committed to ensuring the safety of each patient's surgery as the top priority since the organization was founded in 1999. Through its work with the PSM, the organization thought more comprehensively about creating a culture of safety at its partner hospitals and has made not only the education of providers, but education of patients as well, a top priority. Ensuring that patients can be advocates in their care has added to the safety and quality of Smile Train supported treatments around the world.

Impact Details

Initial Commitment	Commitment Update	Project Next Year
Lives Lost	Lives Lost	Lives Lost:
Lives Spared Harm Target	Actual Lives Spared Harm in last 12 months 0	Lives Spared Harm Target for following calendar year
Lives Saved Target	Actual Lives Saved in last 12 months (might differ from initial target)	Projected Target of Lives Saved for following calendar to try to finish commitment
	New Lives Lost (lives lost – actual lives saved)

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Hospital General Lagos de Moreno

JALISCO

Crear una cultura de seguridad monitorizando, promoviendo el trabajo en quipo del personal de salud y la comunicación franca para disminuir los riesgos y daños al paciente que se atiende en el Hospital General Lagos de Moreno. View Commitment

SSJ HOSPITAL REGIONAL DE AMECA

JALISCO

INCREASING PATIENT SAFETY CULTURE IN THE HEALTH PERSONNEL OF THE AMECA REGIONAL HOSPITAL OF THE JALISCO HEALTH SECRETARIAT. View Commitment

AUMENTAR LA CULTURA DE SEGURIDAD DEL PACIENTE EN EL PERSONAL DE SALUD DEL HOSPITAL REGIONAL DE AMECA DE LA SECRETARÍA DE SALUD JALISCO. View Commitment

PATIENT SAFETY CULTURE AT AMECA REGIONAL HOSPITAL View Commitment

Da-Li Jen Ai Hospital

Da-Li

Patient Safety Culture in order to Raise Healthcare Quality View Commitment

Miaoli General Hospital, Ministry of Health and Welfare

Miaoli County

Challenge 1: Creating culture of safety View Commitment

Kuang Tien General Hospital

Shalu District

Challenge 1: Creating Culture of Safety View Commitment

Desafío 1: Creando una cultura de seguridad View Commitment

Vinci Oncologic Center

Andalucia

Creating Culture of Safety View Commitment

The Bergendahl Institute, LLC

Expand the use of high reliability techniques from the Nuclear Power Industry to improve Patient Safety. View Commitment

Expand the use of high reliability techniques from the Nuclear Power Industry to improve Patient Safety. - Update - 10.03.16 View Update

The Bergendahl Institute, LLC

Expand the use of high reliability techniques from the Nuclear Power Industry to improve Patient Safety. – Update – 10.03.16

Contact Info

Name: Howard Bergendahl

Phone: (440) 476-8754

Email: howard@bergendahlinstitute.com

Position: President

Organization Name: The Bergendahl Institute, LLC

Commitment Details

Commitment Start Date: 09/30/2014

How many hospitals are represented in this commitment?

Last Report
0

Current
0

Action Plan:

Commitment Update:
Educational sessions have been provided to hundreds of healthcare professionals on how patient harm can be avoided using error reduction techniques and safety culture enhancement techniques from the nuclear power industry. Healthcare leaders have have visited and observed the culture and daily practices at several nuclear facilities. Each time positive lessons have been learned and new ideas are being implemented at the healthcare facilities.

Your commitment aligns with APSS
Challenge 1 - Creating a Culture of Safety

Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome

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
Lives Saved Target	Actual Lives Saved in last 12 months (might differ from initial target)	Projected Target of Lives Saved for following calendar to try to finish commitment
	New Lives Lost (lives lost – actual lives saved)

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MEDICA IDEAS, S.A. DE C.V. HOSPITAL INTERMEDICA ® MEDICINA ACTUAL

MÉXICO

CHALLENGE 1: CREATING A CULTURE OF SAFETY, CHALLENGE 2: HEALTHCARE-ASSOCIATED INFECTIONS (HAIs), CHALLENGE 3: MEDICATION ERRORS View Commitment

Feng Yuan Hospital, Ministry of Health and Welfare

Republic of China, Taichung city

Challenge1 Creating Culture of Safety View Commitment

Hoag Memorial Hospital Presbyterian

Avoidable Harm (CAUTI) View Commitment

Avoidable Harm (CLABSI) View Commitment

Avoidable Harm (C diff) View Commitment

Avoidable Harm (Falls) View Commitment

Avoidable Harm (Sepsis) View Commitment

Avoidable Harm (MRSA) View Commitment

Avoidable Harm (Medication Harm) View Commitment

Decrease Sepsis Mortality View Commitment

Avoidable Harm View Commitment

Avoidable Harm - Update View Update

SENSAR

Madrid

Spread of the Patient Safety Culture in anesthesia, critical care and pain management throughout all hospitals in Spain by the implementation of a web based independent non punitive incident reporting system, teaching and training by simulation teamwork and human factors. View Commitment

SENSAR

Contact Info

Name: Daniel Arnal

Phone: (091) 621-9519

Email: darnal@sensar.org

Position: Dr. Anesthesiologist of the Hospital Universitario Fundación Alcorcón. President of SENSAR

Organization Name: SENSAR

Commitment Details

Commitment Start Date: 10/18/2016

How many hospitals are represented in this commitment?

Last Report
0

Current
60

Action Plan:
To achieve this goal we will develop a plan based in Patient safety Education, Patient Safety publications, Protocol Development, Success Reporting, and Hospital engagement. -Patient safety education: Anesthesia Patient Safety Course (twice a year), Crisis Resource Management simulation courses (12 Editions/yr) -Patient Safety publications: SENSAR yearly report, Incident and analysis report (Spanish Anesthesia and Reanimation Journal) every 4 months. SENSAR Anesthesia Crisis Book. -Protocol Development: Serious Adverse Event Protocol, Spanish patient Safety Sedation Standards -Success Reporting: Yearly prices to hospitals actively reporting in the SENSAR incident reporting system. -Hospital engagement: Patient safety lectures provided by SENSAR experts in every hospital to be included in the system (65)

Commitment Update:
We have 102 active hospitals in our network participating in our education, innovative and learning programs. During 2017, 60 Hospitals hace actively reported 1.163 incidents that have produced 2.255 corrective measures locally. Overall, SENSAR has registered more than 8.000 incidents that have been an opportunity for more than 12.000 corrective measures to be implemented since 2009. SENSAR Published a Crisis Manual for Anesthesia and critical patient that have been distributed in 11 speaking countries up to 7.150 copies. These manuals are meant to hung at the anesthesia machine and to be used during crisis to enhance team performance. SENSAR has performed different education programs in coalition with our partners that have engaged more than 1.000 health care givers. These courses have targeted patient safety culture, incident reporting and analysis, crisis resource management, interdisciplinary team performance, and serious adverse event management with compassion, transparency and second victim care. SENSAR has also developed a innovation program with 5 projects: 1- A new Incident reporting and analysis web application: PITELO, that it's been launched during 2017 and it is ready to be translated to different languages to spread the learning culture eventually. 2- A Zero harm seal to acknowledge those hospitals that are active in implementing patient safety in their preoperative setting. 3- A Health care professional patient safety app to help managing crisis, support incident reporting and other patient safety tools. 4- A 3D education program in Patient Safety. 5- A program for patient self-empowerment regarding Patient Safety when facing surgery.

Your commitment aligns with APSS
Challenge 1 - Creating a Culture of Safety

Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
During 2017, 60 Hospitals hace actively reported 1.163 incidents that have produced 2.255 corrective measures locally. Overall, SENSAR has registered more than 8.000 incidents that have been an opportunity for more than 12.000 corrective measures to be implemented since 2009. We find challenges in the continuation of local ledership and management commitment in several hospitals that have led to their decay in incident reporting. To tackle that we have started a rescue program with reduction in education fees for new local patient safety leaders. Also, our activity has grown as much as to move from a voluntary organization to a more professionalyzed one but incomes are yet unsufficient to take that movement.

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
Lives Saved Target 3386	Actual Lives Saved in last 12 months (might differ from initial target) 3394	Projected Target of Lives Saved for following calendar to try to finish commitment
	New Lives Lost (lives lost – actual lives saved)

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Summa Health System

Integrating high reliability behaviors into patient centered medical homes to reduce preventable errors in the primary care delivery system. View Commitment

Dignity Health

Just Culture Training View Commitment

Just Culture Training - Update - 12.28.17 View Update

Dignity Health

Just Culture Training – Update – 12.28.17

Contact Info

Name: Bob Turbow

Phone: 8057393040

Email: bob.turbow@dignityhealth.org

Position: Chief Patient Safety Officer / Neonatologist

Organization Name: Dignity Health

Commitment Details

Commitment Start Date: 01/13/2017

How many hospitals are represented in this commitment?

Last Report
0

Current
5

Action Plan:
We will expand this program from three hospitals to five hospitals.

Commitment Update:
Ongoing training has been provided for Hospital Leadership and the community Boards on Culture of Safety and High Reliability. Additionally, new team members are introduced to the principles during new employee, new nurse, and new physician orientation. When team members are promoted to director, supervisor, or manager, they are enrolled in a three hour in-person training on culture of safety that is taught by certified Just Culture Champions.

Your commitment aligns with APSS
Challenge 1 - Creating a Culture of Safety

Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
Just Culture principles, including system design and behavioral choices, are regularly taught and reinforced. Just Culture is applied in root cause analyses, Walk Rounds, reports to boards, physician peer review, and new employee orientation.

Impact Details

Initial Commitment	Commitment Update	Project Next Year
Lives Lost	Lives Lost	Lives Lost:
Lives Spared Harm Target	Actual Lives Spared Harm in last 12 months 0	Lives Spared Harm Target for following calendar year
Lives Saved Target	Actual Lives Saved in last 12 months (might differ from initial target)	Projected Target of Lives Saved for following calendar to try to finish commitment
	New Lives Lost (lives lost – actual lives saved)

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Sinai Health System

Culture of Safety View Commitment

Culture of Safety - Update View Update

Sinai Health System

Culture of Safety – Update

Contact Info

Name: Sharon Rossmark

Phone: (312) 590-1907

Email: srossmark@aol.com

Position: Vice Chairman, Board of Directors

Organization Name: Sinai Health System

Commitment Details

Commitment Start Date: 12/19/2013

How many hospitals are represented in this commitment?

Last Report
0

Current
8

Action Plan:

Commitment Update:
Sinai Health System (SHS) has added three new CUSP teams, including one at our rehabilitation hospital, and teams in a medical and OB unit. Each unit has shown improvement in culture of safety surveys taken before and after team formation. The teams have worked on a variety of projects determined to be a priority by the team members including: handoffs from ED to surgical inpatient, Falls, timely stat reporting, multidisciplinary rounding, and rapid response in OB. In addition, SHS is adding a new 'Red Rule' for one of our hospitals around patient identification. Sinai Health system intends to to roll that Red Rule out across the health system, learning from the implementation in the first site.

Your commitment aligns with APSS
Challenge 1 - Creating a Culture of Safety

Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome

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
Lives Saved Target	Actual Lives Saved in last 12 months (might differ from initial target)	Projected Target of Lives Saved for following calendar to try to finish commitment
	New Lives Lost (lives lost – actual lives saved)

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Nantou Hospital, Ministry of Health and Welfare

Nantou County

To reduce the serious safety event (SSE) rate View Commitment

Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation

Taiwan (R.O.C.)

Patient Safety Culture in order to Raise Healthcare Quality View Commitment

Taipei Hospital, Ministry of Health and Welfare, Taiwan

TAIWAN(R.O.C.)

Challenge 1-Creating a Culture of Safety View Commitment

London

We are a national campaign covering the NHS in England - our aim is to reduce avoidable harm by 50% and save 6000 lives - bottom up movement approach to change using innovative campaign methodology to support a community of over 270 organisations View Commitment

Jianan Psychiatric Center, Ministry of Health and Welfare

N/A

Creating a Culture of Safety View Commitment

Penghu Hospital, Ministry of Health and Welfare

Taiwan (R.O.C.)

Creating a culture of safety in Penghu hospital View Commitment

Pingtung Christian Hospital

Ping Tung

Using Patient Safety Culture Improvement Tool to Create a Safety Culture View Commitment

Dubai Healthcare City Authority

United Arab Emirates

Creating a Culture of Safety View Commitment

Keelung Hospital Ministry of Health and Welfare

Keelung

Challenge 1-Creating a Culture of Safety View Commitment

Espartanos Grupo Médico

QUERÉTARO

Reanimación óptima View Commitment

Hospital Vera Cruz

São Paulo

Comissão de Risco View Commitment

AL JALILA CHILDREN’S SPECIALTY HOSPITAL

DUBAI

Patient Safety Challenge: Establishing a Culture of Safety View Commitment

Vancouver Coastal Health

British Columbia

Vancouver Acute Psychiatry creating a Sustained and Authentic Culture of Safety for Patients, Staff & Visitors – Pilot project View Commitment

Universidad Anáhuac Querétaro

El Marqués, Querétaro

Creating a Culture of safety View Commitment

Cheng Ching General Hospital Chung Kang Branch

Taichung

Implementation of a Difficult Airway Team in Our Hospital View Commitment

Improve Prevention of Severe Hypoglycemia View Commitment

Decrease the Rate of Ventilator Associated Pneumonia in ICU View Commitment

CHOC Children's Hospital

Providing Triage and Intervention to Primary Psychiatric Patients Presenting to the Emergency Department View Commitment

Averting Severe Pediatric Adverse Drug Events Through Increased Utilization of Smart Pump Drug Libraries for Intravenous Medications View Commitment

Preventing Patient Deterioration View Commitment

Improving Hand Hygiene rate in the NICU by 20% View Commitment

Laerdal Global Health

Norway

Resuscitation and Quality Improvement Program (RQI) View Commitment

Improving Patient Safety through simulation-based training of healthcare personnel- Optimal Resuscitation in Low Income Countries View Commitment

Improving Patient Safety through simulation-based training of healthcare personnel- Optimal Resuscitation in High Income Countries View Commitment

Improving Patient Safety through simulation-based training of healthcare personnel- Neonatal Safety in Low Income Countries View Commitment

Improving Patient Safety through simulation-based training of healthcare personnel- Neonatal Safety in High Income Countries View Commitment

Improving Patient Safety through simulation-based training of healthcare personnel- Nasogastric Feeding and Drainage Tube Placement and Verification in Low Income Countries View Commitment

Improving Patient Safety through simulation-based training of healthcare personnel- Optimizing Obstetric Care in Low Income Countries View Commitment

Helping save 50,000 lives per year by simulation training View Commitment

Intermountain Healthcare

VTE Reduction View Commitment

VTE Reduction - Update - 01.31.18 View Update

Intermountain Healthcare

VTE Reduction – Update – 01.31.18

Contact Info

Name: Robin Betts

Phone: 801-440-0269

Email: robin.betts@imail.org

Position: AVP Quality & Patient Safety

Organization Name: Intermountain Healthcare

Commitment Details

Commitment Start Date: 11/11/2014

How many hospitals are represented in this commitment?

Last Report
0

Current
22

Action Plan:

Commitment Update:
Continued our work outlined in our original commitment working on hardwiring interventions in a highly reliable way and using our EMR to prompt appropriate interventions are ordered and implemented. We also enhanced our patient education program for our total hip and knee replacement surgery program. We bring patients in before surgery for several hours to do comprehensive discharge teaching even before the surgery.

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 above.

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 325	Lives Spared Harm Target for following calendar year
Lives Saved Target	Actual Lives Saved in last 12 months (might differ from initial target) 47	Projected Target of Lives Saved for following calendar to try to finish commitment
	New Lives Lost (lives lost – actual lives saved) 0

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Reduce Catheter Line Associated Blood Stream Infections View Commitment

Reduce Catheter Line Associated Blood Stream Infections - Update - 01.31.18 View Update

Intermountain Healthcare

Reduce Catheter Line Associated Blood Stream Infections – Update – 01.31.18

Contact Info

Name: Robin Betts

Phone: (801) 442-3674

Email: robin.betts@imail.org

Position: Assistant Vice President Quality & Patient Safety

Organization Name: Intermountain Healthcare

Commitment Details

Commitment Start Date: 11/23/2013

How many hospitals are represented in this commitment?

Last Report
0

Current
22

Action Plan:

Commitment Update:
We partnered with a vendor, BARD to come in and do observational assessments of our insertion and maintenance bundles. This let to a re-education program. We also implemented Kamishibai Card process which is taken from Toyota manufacturing Lean Management System. It establishes a peer-to-peer validation process on a daily basis. This accelerated our success.

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 summary above.

Impact Details

Initial Commitment	Commitment Update	Project Next Year
Lives Lost	Lives Lost	Lives Lost: 0
Lives Spared Harm Target	Actual Lives Spared Harm in last 12 months 50	Lives Spared Harm Target for following calendar year 50
Lives Saved Target	Actual Lives Saved in last 12 months (might differ from initial target) 9	Projected Target of Lives Saved for following calendar to try to finish commitment
	New Lives Lost (lives lost – actual lives saved) 0

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Reduce Catheter Associated Urinary Tract Infections (CAUTI) View Commitment

Reduce Catheter Associated Urinary Tract Infections (CAUTI) - Update - 01.31.18 View Update

Intermountain Healthcare

Reduce Catheter Associated Urinary Tract Infections (CAUTI) – Update – 01.31.18

Contact Info

Name: Robin Betts

Phone: (801) 440-0269

Email: robin.betts@imail.org

Position: Assistant Vice President Quality & Patient Safety

Organization Name: Intermountain Healthcare

Commitment Details

Commitment Start Date: 11/28/2013

How many hospitals are represented in this commitment?

Last Report
0

Current
22

Action Plan:

Commitment Update:
We partnered with a vendor BARD to come in and do observational assessments of our insertion and maintenance bundles like we did with CLABSI reduction. This let to a re-education program. We also implemented Kamishibai Card process which is taken from Toyota manufacturing Lean Management System. It establishes a peer-to-peer validation process on a daily basis. This accelerated our success.

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
See summary above.

Impact Details

Initial Commitment	Commitment Update	Project Next Year
Lives Lost	Lives Lost	Lives Lost: 0
Lives Spared Harm Target	Actual Lives Spared Harm in last 12 months 208	Lives Spared Harm Target for following calendar year 297
Lives Saved Target	Actual Lives Saved in last 12 months (might differ from initial target) 5	Projected Target of Lives Saved for following calendar to try to finish commitment
	New Lives Lost (lives lost – actual lives saved) 0

Download

Reduce Adverse Drug Events with Harm View Commitment

Reduce Adverse Drug Events with Harm - Update - 01.31.18 View Update

Commitments

What does it Mean to Make a Commitment to 0X2020TM?

What does it Mean to Make a Commitment to 0X2020^TM?