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What does it Mean to Make a Commitment?

We don’t ask for a financial contribution to join 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

UCI Health

Challenge 2A-Hand Hygiene View Commitment

Challenge 2A-Hand Hygiene - Update - 10.04.19 View Update

UCI Health

Challenge 2A-Hand Hygiene – Update – 10.04.19

Contact Info

Name William Wilson, MD

Phone: 714-456-6844

Email: wcw@uci.edu

Position: Chief Medical Officer

Organization Name: UCI Health

Commitment Details

Commitment Start Date: 01/01/2018

How many hospitals are represented in this commitment?

Last Report
1

Current
1

Action Plan:
• Developed an electronic application in partnership with APIC, GoJo, HQI/HRET to track hand hygiene. This app allows UCI to provide real time feedback and data with unit specific compliance by job role, by the WHO 5 Moments, by discipline. It also enables us to feedback where our misses are with more specificity such as misses before gloving, after gloving, between a task, after contact with environment, poor technique, etc… • Data is collected by name in our Operating Room areas. This is posted in their workrooms to provide full transparency, as well as shared at the physician committees and followed up by their leadership. For areas outside the OR, physician teams and program directors receive unit specific data delineated by Attending, Resident/Fellow, and Medical Students with an expectation for each lead to provide follow up and improvement. • Implemented a more robust observation network that covers the entire span of the hospital and higher risk ambulatory areas, and includes all job roles. The observers cannot be part of this team unless they complete a formal, in person, didactic and training course. They also must commit to at least one year minimally. This provides us with standardized observation definitions and standardized observers. There is a specialized team that has been incorporated into this group that acts as our inter-rater reliability validators. Their data can be separated and used when there are any discrepancies noted. • UCI is in the process of changing out all of our hand gels and soaps to a more superior product line. After a lengthy trial with front line staff, their feedback helped decide on our new products. By installing products that are more skin friendly and staff approved, we hope to increase frequency and compliance through higher staff satisfaction. • In addition to being included in individual unit goals, hand hygiene has been our organization wide goal for 2 consecutive years now which sends a very clear and very strong message across the UCI campus that our senior leadership is in full support as to it’s importance and holds us all accountable for improvement.

Commitment Update:
At UC Irvine Health, the GOJO application was launched in July 2015 and is still actively being used. Compliance reports by location and job disciplines are sent out monthly to unit managers, Medical Directors, and Senior Leadership. Data is also reported to the Epidemiology & Infection Prevention Committee. Data outside of the OR continues to be analyzed to the unit specific level, and furthermore, broken down by type of clinician, Attending, Resident/Fellow, and Medical Student. In the Operating Room, data is reported by name and job discipline and is sent out monthly to the perioperative leaders and Senior Leadership. All hand hygiene data is also reported to the Epidemiology & Infection Prevention Committee. Observers continue to be trained by Infection Prevention to perform hand hygiene observations focusing on the opportunities in the WHO 5 moments for hand hygiene. A separate “inter-rater” reliability team continues to spot check validate. Hand hygiene observations are also performed by trained observers in high risk ambulatory procedural areas. Outside of the high risk ambulatory locations, hand hygiene feedback is provided by the patient after their exam or care using a questionnaire on an electronic tablet. As of January 2019, UC Irvine Health has adopted new hand sanitizer and soap line based on staff feedback. The previous placement of the products were reevaluated and strategic modifications were made to increase accessibility and convenience.

Your commitment aligns with APSS
Challenge 2A - Hand hygiene

Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
UC Irvine Health provides annual training on hand hygiene expectations, and provides constructive feedback to staff on how to improve performance. UC Irvine Health conducted a large trial for selection of new hand hygiene products. The products were trialed by various frontline staff across the organization, and their feedback was evaluated, and highly considered in the product selection. Units were also involved in product placement to ensure accessibility to the products. By installing products that are more skin friendly and staff approved, we hope to increase frequency and compliance through higher staff satisfaction. Leadership supports an ongoing, standardized hand hygiene observer training program. The observers are given dedicated time to perform quality observations. The inter-rater reliability process, with independent validators, ensures that the data collected is accurately representing hand hygiene performance. Ambulatory leadership supports a robust hand hygiene program. Clinics are risk stratified by type of treatment being performed, and an appropriate methodology for collecting the data is applied. For example, a combination of trained observers, patient responses, and patient satisfaction surveys have been implemented across the ambulatory clinics.

Impact Details

Initial Commitment	Commitment Update	Project Next Year
Lives Lost 0	Lives Lost 0	Lives Lost:
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 0
	New Lives Lost (lives lost – actual lives saved)

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Challenge #14: Preventing Falls View Commitment

Challenge #14: Preventing Falls - Update - 10.05.19 View Update

UCI Health

Challenge #14: Preventing Falls – Update – 10.05.19

Contact Info

Name WILLIAM WILSON

Phone: 714-456-6844

Email: wcw@uci.edu

Position: Chief Medical Officer

Organization Name: UCI Health

Commitment Details

Commitment Start Date: 01/01/2018

How many hospitals are represented in this commitment?

Last Report
1

Current
1

Action Plan:
We have periodical Assessment of our existing fall prevention program, including tools, interventions, and outcomes. We have been modifying our program based on evidence provided by research and trends from analyzing our own data. Employees have Computer based training as well as selected events are shared with and presented at the unit practice council and the division council. We have been debriefing falls for the last 7-8 years, where the team immediately meet after a fall and use a form to guide staff in the debrief process. Falls data are collected and analyzed by the Falls Prevention PI team every month (ACA). Recommendations are made based on the outcomes and findings of the ACA. Fall Prevention PT team is a multidisciplinary lead by a clinical nurse specialist, and nursing director. Members are: nurse managers, staff nurses, nursing AIDs, Physical therapy, MD, and Risk management. Each unit has a fall champion whose goal is to monitor fall trends and provide education as needed. One of our champions conducted a survey where she interviewed all patients at risk for falls to know if they knew why they are at risk for falls and what do they need to do to prevent a fall and injury. Based on that survey we modified our education to teach back method. We based our intervention on our analysis of the trends and any specific findings. A nurse, a manager or a designated person will present the falls of their unit to the PI team and a discussion will take place on what was done and how to improve conditions for patients. One of the mandatory interventions is for staff to be within arm reach of the patient who is deemed at risk during the critical times (toileting, ambulation, and transfer). Video monitoring, bed alarms, gait belts, Posey alarms, non-slip cushions, and more tools are available for staff to utilize to protect patients based on their unique situation and plan of care. Post fall algorithms identify post fall assessment, and monitoring required by staff. Falls data are reported to CALNOC and NDNQI and results are shared with staff and managers.

Commitment Update:
We continue to practice out the above mentioned activities, in addition we have modified our fall prevention tool based on the most current literature, and we also gave nurses the ability to override the tool if and when they feel the patient is at risk and the tool is not capturing the risk. We also updated our policy and spelled out all the expectations in all different setting, like ED, Psych, outpatient and inpatient to make it easier for staff to find their area of practice guideline. Our Fall Prevention PI team is discussing with infection control, environmental and upper management to change the floor material for the showers in the DH to make it more resistant and less slippery. We will continue to monitor and report findings to make sure our patients remain safe.

Your commitment aligns with APSS
Challenge 14A - Falls and fall prevention in adults

Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
We have learned that it takes a village to prevent a fall and will need all discipline to be involved to assure the safety of our patients. We also learned that patients need to be assessed frequently to remove those who are not at risk any more to focus efforts on those who are at risk. We may not know the number of lives we saved but we know that all the efforts we put in place has kept our patients safe.

Impact Details

Initial Commitment	Commitment Update	Project Next Year
Lives Lost 0	Lives Lost 0	Lives Lost: -63
Lives Spared Harm Target 0	Actual Lives Spared Harm in last 12 months 63	Lives Spared Harm Target for following calendar year
Lives Saved Target 0	Actual Lives Saved in last 12 months (might differ from initial target) 63	Projected Target of Lives Saved for following calendar to try to finish commitment
	New Lives Lost (lives lost – actual lives saved) -63

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Challenge #1: Improving Safety Culture View Commitment

Preventing CLABSI View Commitment

Preventing CLABSI - Update - 10.04.19 View Update

UCI Health

Preventing CLABSI – Update – 10.04.19

Contact Info

Name WILLIAM WILSON

Phone: 714-456-6844

Email: wcw@uci.edu

Position: Chief Medical Officer

Organization Name: UCI Health

Commitment Details

Commitment Start Date: 01/01/2018

How many hospitals are represented in this commitment?

Last Report
1

Current
1

Action Plan:
- Use a standardized process, including a checklist for central line insertion - Use a standardized kit and process for central line dressing changes - Use chlorhexadine (CHG) for patient bathing - Use a systematic process to daily access the central line insertion site and need for removal - Develop and implement use of materials to promote peer to peer hand hygiene accountability CLABSI core improvement team is in place. CLABSI cases provided to unit manager and Medical Director for review. "1,2,3… Count w/Me" continuing in 2018. OC Shield Project housewide - CDC public healthcare initiative targeting reduction of MDROs across the healthcare continuum through decolonization with CHG bathing and nasal iodophor for all adult ICU and contact isolation patients. Nursing educators providing support with the central line care best practices with roving cart education ongoing. Central line rounds conducted on outlier units focusing on insertion site and dressing appearance. CLISA is being transitioned into Epic.

Commitment Update:
Used a systematic process to evaluate central line insertion site and daily assessment for removal; Documentation embedded in Epic. Implemented institution wide scrub the hub practice with nurse and patient/family participation. Daily chlorhexidine bathing and nasal iodophor decolonization for all adult ICU and contact isolation precaution patients. Central line rounding in outlier units. Targeted PI on units with outlier CLABSI performance. Development of an apparent cause analysis form to review CLABSI cases; in progress. New central line dressing product was implemented throughout organization. Central line education video assigned to nursing staff annually. In late 2017, the medical record program transition to Epic resulting in loss of functionality / processes related to central line documentation and central line assessment communication. CLABSI cases were at an all time low in the last 3 months of 2018, with 1 case housewide. CLABSI Performance Improvement Team is active. CLABSI cases provided to unit manager and Medical Director for review.

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
Supporting compliance with basic best dressing practice has been a key focus in efforts to sustain CLABSI reduction. Staff desire visual demonstrations for appropriate use of products and sequencing of dressing changes, therefore an in-house video was developed. This has helped keep practice consistent and expectations very clear. Dressing change policy has remained at once per week and as needed. This scheduled systematic approach supports accountability and consistency.

Impact Details

Initial Commitment	Commitment Update	Project Next Year
Lives Lost 0	Lives Lost 0	Lives Lost:
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 0
	New Lives Lost (lives lost – actual lives saved) 0

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Preventing CDI View Commitment

Preventing CDI - Update - 10.04.19 View Update

UCI Health

Preventing CDI – Update – 10.04.19

Contact Info

Name WILLIAM WILSON

Phone: 714-456-6844

Email: wcw@uci.edu

Position: Chief Medical Officer

Organization Name: UCI Health

Commitment Details

Commitment Start Date: 01/01/2018

How many hospitals are represented in this commitment?

Last Report
1

Current
1

Action Plan:
PCR vs Toxin EIA testing validation in progress. Swabbing test validation (vs stool specimen); in progress. Clinician notification of inappropriate override C.diff orders in progress. Continued focus on hand hygiene compliance and environmental cleaning. Transitioning best practices into Epic to notify MDs of CDI ordering protocol.

Commitment Update:
Clinical teams and leadership are notified of each C. difficile case as it arises and opportunities for improvement are suggested/reviewed. Apparent Cause Analysis performed on every nosocomial C.difficile case. Analysis includes appropriateness of testing, informational technology gaps in electronic ordering, trends in admission source, and compliance with testing protocol. Ongoing clinician notification of inappropriate overrides for C.difficile orders. Validation of PCR/EIA toxin testing completed. Transitioned to 2-step PCR/EIA Toxin testing. Rectal swab testing completed; now in analysis phase. Best practices transitioned into Epic electronic medical record ordering pathway. This provides ability to monitor appropriateness of testing Initiative for improved EVS processes continue. Development of environmental services competency completed. Infection Prevention Dept and Environmental Services interrater reliability validation of environmental cleaning is in progress. In early phases of developing hand hygiene campaign with Marketing.

Your commitment aligns with APSS
Challenge 2E - Clostridioides difficile infection (CDI)

Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
Multidisciplinary collaborative approach with interventions and improvement plans. Use your EHR to your advantage; hard stops or best practice alerts in EHR can significantly assist in preventing and monitoring over testing or inappropriate C.difficile orders.

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 0
	New Lives Lost (lives lost – actual lives saved) 0

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Preventing SSI-Colon Surgery View Commitment

Preventing SSI-Colon Surgery - Update - 10.04.19 View Update

UCI Health

Preventing SSI-Colon Surgery – Update – 10.04.19

Contact Info

Name WILLIAM WILSON

Phone: 714-456-6844

Email: wcw@uci.edu

Position: Chief Medical Officer

Organization Name: UCI Health

Commitment Details

Commitment Start Date: 01/01/2018

How many hospitals are represented in this commitment?

Last Report
1

Current
1

Action Plan:
Ongoing outcomes review and preventive measures implementation with Colorectal and General Surgery Chiefs. Reporting division and surgeon-specific data. Maintaining high compliance with pre-op CHG bathing. Standardization of alcohol-CHG containing skin prep use for colorectal patients. Issuing standardized patient wound care discharge education and transfer instructions. Implementation of mechanical bowel prep and oral ABs administration for elective colorectal resection cases. Revision of surgical prophylactic protocol in collaboration with the Antibiotic Stewardship Committee. A multidisciplinary Task Force with Colorectal Chief, CMO, Anesthesia, EIP and Quality Improvement. Task Force is looking into pre-op patient preparation (bowel prep with low residue diet and oral antibiotics), intra-op (increasing FiO2 to 80%), discharge measures (ostomy education, surgical site infection patient education).

Commitment Update:
Ongoing multidisciplinary implementation of colorectal perioperative surgical site infection prevention practices. • Overall high compliance with pre-op CHGx3 bathing has been achieved (2018 = 87%). • Carbo loading (Maltodextrin) trial conducted in September 2017 – February 2018 with positive impact on reduction of surgical site infection. • Ongoing mechanical bowel prep and oral antibiotics administration for elective colorectal resection cases (Miralax, Neomycin + Flagylx3). • High adherence to pre-operative surgical prophylactic antibiotics practices: appropriate choice, dose, administration timing. • High compliance with keeping patients warm in OR (2018 sample = 100%). • High compliance with alcohol-containing surgical skin prep (2018 sample = 100%). • Standardized use of abdominal wound closure tray. • Implemented use of PICO negative wound dressing when appropriate (high BMI pts). • Post-op CHG bathing compliance overall is high (2018 sample = 86%). Continued work on technique and application of CHG cloths over the incision line. • Assuring that standardized wound care instructions handout is issued consistently. • Working on assuring high oxygenation intra-op (FiO2). • Trialing intra-op surgical wound 0.05% CHG irrigation/lavage. • Sharing best practices among General Surgery Divisions, ongoing surgical site infection (SSI) cases review with Surgical Quality Committee.

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
Multidisciplinary approach allowed to garner extensive expertise and secured the commitment for this patient safety/quality improvement effort. Detailed SSI cases review and internal reporting of compliance with the surgical site infection best practices helped to identify targeted interventions. Ongoing outcomes review and action plan updates at the Safety and Quality Crosswalk Task Force meetings assured consistent focus for performance improvement.

Impact Details

Initial Commitment	Commitment Update	Project Next Year
Lives Lost 0	Lives Lost 0	Lives Lost:
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 0
	New Lives Lost (lives lost – actual lives saved)

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Preventing SSI-Abdominal Hysterectomy View Commitment

Preventing SSI-Abdominal Hysterectomy - Update - 10.04.19 View Update

UCI Health

Preventing SSI-Abdominal Hysterectomy – Update – 10.04.19

Contact Info

Name WILLIAM WILSON

Phone: 714-456-6844

Email: wcw@uci.edu

Position: Chief Medical Officer

Organization Name: UCI Health

Commitment Details

Commitment Start Date: 01/01/2018

How many hospitals are represented in this commitment?

Last Report
1

Current
1

Action Plan:
Ongoing outcomes review and preventive measures implementation with GYN ONC Chief. Reporting surgeon-specific data. Re-enforcement of pre-op, intra-op measures, post-op care and discharge care practices: maintaining high GYN patient pre-op CHG bathing compliance. Standardization of alcohol-CHG containing skin prep use for GYN patients. Implementation of timely re-dosing of intra-op prophylactic surgical antibiotic with Anesthesia and Surgeon, include re-dosing assessment based on estimated case duration into Timeout process, and timing reminders for Anesthesia. Engage OBGYN department into additional measures to reduce the risk of surgical site infection: (1) development/implementation of standardized wound care discharge instructions; transfer instructions for GYN ONC patients; (2) development of criteria for application and use of negative pressure wound therapy (PICO dressing), patient PICO dressing discharge care instructions.

Commitment Update:
Ongoing multidisciplinary implementation of abdominal hysterectomy perioperative surgical site infection prevention practices. • Overall high compliance with pre-op CHGx3 bathing has been achieved (2018 = 84%). • Administration of bowel prep (Miralax) and oral antibiotics for surgical cases when colon resection is expected (abdominal tumor cases). • To align with American College of Obstetricians and Gynecologists (ACOG) and national medical professional organizations recommendations, medical center has implemented use of 4% CHG solution for perineal and vaginal surgical prep (July 2018). • High compliance with alcohol-containing surgical skin prep (2018 sample = 92%). • High adherence to pre-operative surgical prophylactic antibiotics practices: appropriate choice, dose, administration timing. Standardization of antibiotic selection: Ceftriaxone and Flagyl for cases that may involve bowel resection. Updating the Pre-op Order Set that is used to order the antibiotics. • High compliance with keeping patients warm in OR (2018 sample = 100%). • Ongoing efforts on implementation of Enhanced Recovery After Surgery (ERAS) protocol. • Abdominal closure trays for GYN ONC surgery that include new sterile gown, gloves, light handles and instruments have been implemented in February 2019. • Standardized technique for negative pressure wound dressings and negative pressure wound therapy placement (specified indications for use: BMI >35). • Working on increasing compliance with daily post-op CHG treatments while in house post-op. • Collaborative work with Anesthesiology Services to administer high FiO2 (80%) for cases that involve a bowel resection, extension of high FiO2 into recovery period via a facemask. • Assuring that standardized wound care instructions handout is issued consistently.

Your commitment aligns with APSS
Challenge 2C - Surgical site infections (SSI)

Impact Details

Initial Commitment	Commitment Update	Project Next Year
Lives Lost 0	Lives Lost 0	Lives Lost:
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 0
	New Lives Lost (lives lost – actual lives saved)

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Preventing CAUTI View Commitment

Preventing CAUTI - Update - 10.04.19 View Update

UCI Health

Preventing CAUTI – Update – 10.04.19

Contact Info

Name WILLIAM WILSON

Phone: 714-456-6844

Email: wcw@uci.edu

Position: Chief Medical Officer

Organization Name: UCI Health

Commitment Details

Commitment Start Date: 01/01/2018

How many hospitals are represented in this commitment?

Last Report
1

Current
1

Action Plan:
New suction canisters are now in-house to measure strict output for urine. Purewick device launched. Working with nursing students to perform potential observations for compliance with care (CDC CAUTI bundle). EMR work underway re: daily device necessity.

Commitment Update:
From the initial action plan, there have been multiple interventions that have been successfully implemented in an on-going effort to reduce Catheter Associated Urinary Tract Infections (CAUTIs). With consideration of providing the right tools for the job, efforts have been successful with providing both male and female external urinary devices that provide effective alternatives to indwelling catheters. After receiving buy-in and support from frontline staff, extensive education and awareness campaigns were completed to promote the usage of these new devices – which has resulted in an overall reduction in indwelling catheter usage. To assist with developing a collaborative, multi-disciplinary approach to CAUTI reduction, a CAUTI Performance Improvement (PI) team was formed with representatives from multiple specialties. The formation of this team has yielded the identification of a need for, and subsequently the completion of a Urinary Retention Algorithm to assist in guiding and standardizing the management of Acute Urinary Retention. Additionally, the CAUTI PI Team has developed and implemented a CAUTI rounding tool. This rounding tool is effective at removing indwelling catheters in a timely manner when no longer indicated, promoting critical thinking for possible alternatives available, and educating on best practices if an indwelling catheter is still required. Additional interventions that are also being employed include: Apparent Cause Analysis (ACA) when CAUTIs are identified; care review is presented to identify opportunities for improvement and inspire practice change; improved access and utilization of bladder scanners; EMR update to include assessment for device need; and, on-going nursing education on CAUTI prevention. The previously noted efforts, in conjunction with the strong foundational knowledge present at UCI Health, has led to a reduction in CAUTIs below the DHHS benchmark target.

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
Throughout the on-going effort of CAUTI reduction, there have been a few key takeaways that are important to consider when implementing strategies. This includes involvement and inclusion of key stakeholders that represent multiple specialties, and different professions. The insight, practices, and general knowledge that these stakeholders provide from the different units is invaluable at identifying opportunities for practice improvement. As an example, representatives from the Operating Room and Emergency Department provided significant information that allowed for improvement in insertion technique at UCI Health. Additionally, the development of a standardized process to identify opportunities for timely removal of indwelling urinary catheters, the most effective method of reducing risk of CAUTI, is critical for establishing consistent practice. Some challenges encountered throughout the implementation of new strategies included: effective communication of the changes; and, comprehensive education of those affected stakeholders. Fortunately, having anticipated these challenges, effective mitigation strategies were developed as part of implementation strategies, and assisted in improving overall effectiveness of campaigns.

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 0
	New Lives Lost (lives lost – actual lives saved) 0

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Improving Medication Harm Errors View Commitment

Improving Medication Harm Errors - Update - 10.04.19 View Update

UCI Health

Improving Medication Harm Errors – Update – 10.04.19

Contact Info

Name WILLIAM WILSON

Phone: 714-456-6844

Email: wcw@uci.edu

Position: Chief Medical Officer

Organization Name: UCI Health

Commitment Details

Commitment Start Date: 01/01/2018

How many hospitals are represented in this commitment?

Last Report
1

Current
1

Action Plan:
A Medication Safety Team is in place. All medication errors are reviewed for trends, severity of harm and actions for improvement. Opioid use is under review with the intent to reduce use as appropriate and to prevent ADEs related to opioid use.

Commitment Update:
Medication Safety Team continues to review medication errors reported by staff. ADEs related to opioid use are reviewed for opportunity to improve the system such as revising order sets for clearer Prescribing Instructions, dose limits,... The organization has focus on improving errors related to chemotherapy in the past year and has made significant improvement to the electronic health record as well as communication and workflow.

Your commitment aligns with APSS
Challenge 3A - Medication errors

Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
Lessons learned: For chemotherapy: 1. Have as many orders and order sets/treatment plans pre-built and tested in the electronic health record as possible. 2. Have clear medication names and route with appropriate dosing prefilled for each route 3. Utilize hard stops for upper dosing limits when possible for high risk drugs, routes (such as intrathecal,...) Challenges: 1. New electronic health record so many workflows/processes need to be worked on. Staff is not as proficient in using the electronic health record. 2. Low number of reported incidents from staff

Impact Details

Initial Commitment	Commitment Update	Project Next Year
Lives Lost 0	Lives Lost 0	Lives Lost:
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 0
	New Lives Lost (lives lost – actual lives saved)

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Antimicrobial Stewardship View Commitment

Antimicrobial Stewardship - Update - 10.04.19 View Update

UCI Health

Antimicrobial Stewardship – Update – 10.04.19

Contact Info

Name WILLIAM WILSON

Phone: 714-456-6844

Email: wcw@uci.edu

Position: Chief Medical Officer

Organization Name: UCI Health

Commitment Details

Commitment Start Date: 01/01/2018

How many hospitals are represented in this commitment?

Last Report
1

Current
1

Action Plan:
An Antimicrobial Stewardship Program is established at UC Irvine Health. Implementing Vancomycin pharmacokinetic dosing per Pharmacy for patient safety. IV to PO conversions are being monitored on a monthly basis.

Commitment Update:
UC Irvine implemented Vancomycin Dosing Per Pharmacy program in January 2018 with the goal to further ensure the safety of vancomycin use for patients hospitalized at UC Irvine. According to Safety and Quality Information System (SQIS), a program used to track adverse events, there was zero report of vancomycin associated nephrotoxicity for 2018. A quality assurance process was also established and will be used to track nephrotoxicity associated with vancomycin.

Your commitment aligns with APSS
Challenge 3B - Antimicrobial stewardship

Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
When implementing new programs on patient safety, it is important to monitor and track associated outcomes to provide feedback to staff to ensure both compliance and safety, and to promptly identify new opportunities for improvement. The criteria that were built pre-implementation for performing staff to notify program manager(s) were beneficial, promoting effective communications.

Impact Details

Initial Commitment	Commitment Update	Project Next Year
Lives Lost 0	Lives Lost 0	Lives Lost:
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 0
	New Lives Lost (lives lost – actual lives saved)

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Preventing Insulin-Induced Hypoglycemia View Commitment

Preventing Insulin-Induced Hypoglycemia - Update - 10.04.19 View Update

UCI Health

Preventing Insulin-Induced Hypoglycemia – Update – 10.04.19

Contact Info

Name WILLIAM WILSON

Phone: 714-456-6844

Email: wcw@uci.edu

Position: Chief Medical Officer

Organization Name: UCI Health

Commitment Details

Commitment Start Date: 01/01/2018

How many hospitals are represented in this commitment?

Last Report
1

Current
1

Action Plan:
Multiple multi-disciplinary teams have been established to address this challenge. Events are reviewed and categorized as preventable vs non-preventable. Aim is to reduce preventable hypoglycemia among all patients (not just those associated with insulin). Insulin order sets have been developed to reduce occurrence of insulin-associated hypoglycemia. NPO order sets are in place and periodic re-education/reinforcement of use is ongoing. A hyperkalemia order set is also available for use.

Commitment Update:
The order sets are used widely. In 2019-2020 Glycemic Control Team plans to re-educate staff on appropriate insulin dosing and hypoglycemia prevention strategies. The team is also exploring a different approach: Nursing staff to perform carb count after meals so that nutritional insulin can be administered appropriately afterward.

Your commitment aligns with APSS
Challenge 3C - Severe hypoglycemia

Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
1. Decrease home dose insulin while the patient is admitted due to inactively and change of diet 2. Ensure a dextrose source is ordered for the patient when the NPO order is selected Challenges: 1. Patients may not eat the full meal as anticipated, so administering nutritional insulin dose prior to meal may result in overdosing and cause hypoglycemia. 2. Staff (new and existing) needs to be educated and re-educated on the subject.

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 0
	New Lives Lost (lives lost – actual lives saved) 0

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Challenge 3D-Preventing Newborn and Pediatric Adverse Drug Events View Commitment

Challenge 3D-Preventing Newborn and Pediatric Adverse Drug Events - Update - 10.04.19 View Update

UCI Health

Challenge 3D-Preventing Newborn and Pediatric Adverse Drug Events – Update – 10.04.19

Contact Info

Name WILLIAM WILSON

Phone: 714-456-6844

Email: wcw@uci.edu

Position: Chief Medical Officer

Organization Name: UCI Health

Commitment Details

Commitment Start Date: 01/01/2018

How many hospitals are represented in this commitment?

Last Report
1

Current
1

Action Plan:
Newborn and Pediatric adverse drug events and medication errors are reviewed monthly with a multi-disciplinary team. Aim is to decrease preventable errors and ADEs. Actions underway include: -The SQIS Incident Reporting system is utilized to report ADEs for analysis, trending and performance improvement -eMAR and barcoding for medication administration has been implemented -Standardized order sets are established which include pharmaceutical administration -CPOE has long been in place at UC Irvine Health; mechanisms for medication reconciliation, allergy checking, interaction and dose range checking with alerts exist in Epic -Pharmacist rounding, including double-check processes has been implemented for newborn and pediatric patients -Nurses review the MAR during their standardized hand-off process -Smart drug infusion pumps are utilized, with drug libraries appropriate to the population served -The EMR provides support for weight-based prescribing, compounding dispensing and administration, although further refinement would be beneficial in this area -

Commitment Update:
Multidisciplinary team continues to review ADEs reported to identify trends and opportunities for improving the system. All other actions are in place. UCI Health specific dosing reference for the NICU was added to the electronic health record so it is easier for all staff to double-check the appropriateness of each medication order. In 2019 the organization is looking into putting dosing hard stops for high risk drugs such as electrolytes, continuous drips,... in the electronic health record.

Your commitment aligns with APSS
Challenge 3D - Pediatric adverse drug events

Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
Challenges: 1. Limited resource from IT to add the dosing hard stops into the electronic health record so project may take longer than desired 2. Small pediatric population so very small number of errors reported

Impact Details

Initial Commitment	Commitment Update	Project Next Year
Lives Lost 0	Lives Lost 0	Lives Lost:
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 0
	New Lives Lost (lives lost – actual lives saved)

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Preventing Failure to Rescue View Commitment

Improvement of Patient Blood Management View Commitment

APSS #6 Improving Hand Off Communications View Commitment

Improving Neonatal Oxygen Targeting View Commitment

Improving Detection of Critical Congenital Heart Disease View Commitment

Safer Airway Management View Commitment

Challenge 8B: Preventing Unplanned Extubations View Commitment

Challenge 8B: Preventing Unplanned Extubations - Update - 10.05.19 View Update

UCI Health

Challenge 8B: Preventing Unplanned Extubations – Update – 10.05.19

Contact Info

Name WILLIAM WILSON

Phone: 714-456-6844

Email: wcw@uci.edu

Position: Chief Medical Officer

Organization Name: UCI Health

Commitment Details

Commitment Start Date: 01/01/2018

How many hospitals are represented in this commitment?

Last Report
1

Current
1

Action Plan:
Unplanned extubations have been tracked in the Neonatal ICU (NICU) since 2008. This is reported to the unit for tracking and intervention. Interventions have included elimination of inline suctioning, standardized ET tube holder, bedside safety practices such as two providers for high risk procedures such as suctioning, linen change, chest X-ray. A nursing project focused on unplanned extubations in the NICU population--findings indicated standardized roles and communication would be valuable; subsequent implementation of these practices has occurred. Housewide, a standardized ET tube holder has also been implemented, with isolated exceptions. Investigation is underway to determine if an EMR core data set from Epic is available for analysis and performance improvement. Data on unplanned extubations are also entered into our incident reporting system for review by Respiratory Care for trends. A difficult airway algorithm is in development to identify patients with known difficult airways. This year 15 additional ventilators were purchased with wave form capnography.

Commitment Update:
In the Neonatal ICU the unplanned extubation committee continues to meet to review all cases looking for trends and opportunities for performance improvement. To aid in better visibility of the endotracheal tube and ventilator circuit during surgery, the committee is reviewing the NICU's procedure for draping patients before surgery and evaluating different surgical drape products. In addition a bedside tool displaying the depth and size of the endotracheal tube has been implemented to increase awareness of correct positioning. Housewide, changes were made to the EMR for more detailed documentation on unplanned extubations. These modifications facilitate better data entry and ease of chart review, as well as regular reporting. In addition a difficult airway algorithm has been implemented to identify those patients with known difficult airways.

Your commitment aligns with APSS
Challenge 8B - Unplanned extubation

Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
A multidisciplinary approach has been the most valuable lesson learned. While modifications in practice made progress toward the goal, the most significant improvement began when the team had representation from all bedside disciplines including physicians, nurses, respiratory therapists and physical therapists.

Impact Details

Initial Commitment	Commitment Update	Project Next Year
Lives Lost 0	Lives Lost 0	Lives Lost:
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)	Projected Target of Lives Saved for following calendar to try to finish commitment 0
	New Lives Lost (lives lost – actual lives saved) 0

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APSS #9 Preventing Sepsis View Commitment

APSS #9 Preventing Sepsis - Update - 10.04.19 View Update

UCI Health

APSS #9 Preventing Sepsis – Update – 10.04.19

Contact Info

Name WILLIAM WILSON

Phone: 714-456-6844

Email: wcw@uci.edu

Position: Chief Medical Officer

Organization Name: UCI Health

Commitment Details

Commitment Start Date: 01/01/2018

How many hospitals are represented in this commitment?

Last Report
1

Current
1

Action Plan:
The focus of our efforts through the Sepsis Committee is to increase compliance with current evidence-based guidelines. A dashboard has been created for tracking of compliance with the sepsis bundle elements. Data and non-complaint cases are disseminated to physician leads and sepsis committee for review and to identify opportunities for improvement. Case information and education is discussed and provided as needed to physicians, nurses and pharmacists. Additionally, information related to processes and protocols, current guidelines, IT system upgrades, chart addenda, coding changes/corrections and corrective improvement actions are discussed at the Sepsis Team meeting as needed. Electronic workflows to facilitate best practice and appropriate, timely treatment have been previously implemented and are being refined due to transition to a new EMR. An order set for sepsis care is also being embedded into the new EMR. A nurse-driven sepsis screening system has been implemented for early identification of potential sepsis cases and use of a care algorithm. Sepsis is monitored by hospital leadership through the organizational crosswalk for progress accountability.

Commitment Update:
To increase compliance with current evidence-based guidelines for sepsis an evaluation of our nurse-driven sepsis screening best practice alert (BPA) was completed. It was determined that the electronic screening tool and alert system in the EMR were not effective, it was not triggering accurately and was also did not align with the current workflow. The screening process required an update. All patients will be screened/assessed/reassessed for sepsis, severe sepsis, &/or septic shock in the ED and upon admission to all inpatient floors and/or units. The sepsis assessment tool will be completed in the electronic medical record (EMR) by the Registered Nurse (RN). To evaluate and/or update the patient’s status, to reflect changes, and/or to address additional treatment needs, ongoing reassessment will occur throughout hospitalization. The next step was to implement a standardized, physician approved, nursing protocol. The physician approved protocol has been implemented hospital wide. The nurse driven order allows the RN to assess and/or screen patients for Sepsis, Severe Sepsis or Septic Shock, and protocol-based nursing interventions will allow the RN to initiate early treatment, by drawing blood cultures and Lactates. Guidance has been provided to the nursing staff on information that should be communicated to the physician when patients screen positive for Sepsis. To address progress and accountability sepsis is monitored by hospital leadership through our sepsis dashboard, the dashboard includes monitoring SEP-1 bundle adherence, sepsis mortality, sepsis readmissions, length of stay, and post-operative sepsis. There is currently an ongoing evaluation for the implementation of a reflux order for “Repeat Sepsis Lactate” this would include a notification by the lab whenever a “Sepsis Lactate” is above 2. A suspected sepsis order set is now embedded into our EMR.

Your commitment aligns with APSS
Challenge 9 - Early detection and treatment of sepsis

Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
Reinforcing the importance of adhering to the Surviving Sepsis Campaign guidelines the revision. Implementation of a standardized suspected sepsis order set. Evaluation and monitoring of an electronic best practice alert for early awareness and identification of sepsis. Implementation of a nurse driven order set which allows the nurse to draw blood cultures and lactates. Implementation of sepsis simulation education sessions. Implementation of a UCI Health Sepsis Awareness Day.

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 0
	New Lives Lost (lives lost – actual lives saved) 0

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APSS #10 Ensuring Optimal Resuscitation View Commitment

Preventing Postpartum Hemorrhage View Commitment

Preventing Postpartum Hemorrhage - Update - 11.04.19 View Update

UCI Health

Preventing Postpartum Hemorrhage – Update – 11.04.19

Contact Info

Name WILLIAM WILSON

Phone: 714-456-6844

Email: wcw@uci.edu

Position: Chief Medical Officer

Organization Name: UCI Health

Commitment Details

Commitment Start Date: 01/01/2018

How many hospitals are represented in this commitment?

Last Report
1

Current
1

Action Plan:
UCI Health uses the CMQCC Toolkit for Prevention & Management of Post-Partum Hemmorhage. Risk is assessed on admission (low, medium & high); based on risk assessment, protocols and plans are followed and are revised based on patient need. For example, anticipated need for uterotonics, blood product needs or potential use of RIP protocol. There is also a formalized family support system for patients that experience a stage 3 hemmorhage. UCI has completed all 16 elements of the toolkit. OB Hemorrhage simulation scenarios are offered every three months by the interprofesssional perinatal simulation team with the objectives of streamlining the process of ordering blood, utilization of equipment of BAKRI balloon and EBB, and the recommendations of the CMQCC tool kit interventions.

Commitment Update:
A. Updates/Actions 1. Quarterly OB Hemorrhage simulations were performed by multidisciplinary Simulation team. OB and Anesthesia Physicians and Perinatal RNs participated in the OB hemorrhage simulations scenarios that had objectives including the use of the Bakri Balloon and EBB balloon, the process of ordering blood and pick up and a review of the process of quantitative blood loss. Debriefs were performed after all simulations. 2. The medication TXA was added to Anesthesia cart to support easy access of the medication that helps with hemorrhage. 3. OB hemorrhage protocol reviewed and revised by both nursing and physicians. 4. The 2019 perinatal skills day (Mandatory) had a station that provided hands on training on how to use the Bakri balloon. 5. The nurses can access it via the Admission navigator, or via Shift Required Doc and document admission Hemorrhage Risk. 6. Epic charting for the AWHONN “Post-Birth Hemorrhage Risk” to the OB Recovery Flowsheet was developed. On the flowsheet, the Post-Birth Hemorrhage Risk will display above the Complication-Post Partum Hemorrhage entry. There is an option adding to the Post-Birth Hemorrhage Risk-BPA (Best Practice Advisory) that will automatically create a pop-up that will allow the nurse to enter a lab order for a type and crossmatch.

Your commitment aligns with APSS
Challenge 11A - Postpartum hemorrhage (PPH)

Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
Best practices B. Best Practices/Lessons learned 1. Utilization of the Admission Hemorrhage Risk flowsheet via the Admission navigator, or via Shift Required Doc. i. This enables the nurse to chart directly to the flow sheet without going to another document. 2. New scales were provided to all LDRPs to support quantification of blood loss. 3. Perinatal Centricity Connect upgrade has the OB hemorrhage risk assessment panel to view the criteria for the risk level. Both nursing and medical team have access to this fetal monitoring upgrade. 4. Re-emphasize the use of communication techniques such as “ SBAR, code words like “Zot” notes and “ Time outs”.

Impact Details

Initial Commitment	Commitment Update	Project Next Year
Lives Lost 0	Lives Lost 0	Lives Lost:
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 0
	New Lives Lost (lives lost – actual lives saved) 0

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APSS # 11B Optimizing Management of Pre-eclampsia View Commitment

Challenge 11C: Preventing Unnecessary C-Sections View Commitment

Challenge 11C: Preventing Unnecessary C-Sections - Update - 10.05.19 View Update

UCI Health

Challenge 11C: Preventing Unnecessary C-Sections – Update – 10.05.19

Contact Info

Name WILLIAM WILSON

Phone: 714-456-6844

Email: wcw@uci.edu

Position: Chief Medical Officer

Organization Name: UCI Health

Commitment Details

Commitment Start Date: 01/01/2018

How many hospitals are represented in this commitment?

Last Report
1

Current
1

Action Plan:
• Looked into every NTSV case 2016-17. Found that most inductions were medically indicated (only 1 or 2 elective inductions), NTSV C/S were primarily for Cat II tracing remote from delivery and Arrest of Descent (2nd stage labor arrest). Every failed induction met the new recommended criteria (i.e. 12-18 hours, ruptured on pitocin) and all labor arrests followed the ACOG recommendations (e.g. 1st stage: 6 hours ruptured on pitocin with inadequate contractions or 4 hours with adequate contractions; 2nd stage: 3-4 hours of pushing depending on epidural and parity). • Actions o FHR tracings:  Perinatal Quality Foundation Exam by all MDs/RNs Standardizing NICHD terminology and strip interpretation  Cat II FHR tracing algorithm implemented o 2nd Stage labor:  2nd stage evidenced-based labor algorithms implemented  Peanut balls to facilitate labor management and vaginal delivery  Labor management classes for RNs  OVD education for MDs • Grand Rounds • Resident lectures o Grand Rounds reviewing all this information last Fall o Individualized score cards o Monthly newsletters with stats - Perinatal in situ simulation - Track, monitor and report metrics monthly at OB Quality and Safety and Grand Rounds, annually at QSOC - Implementation of standard induction scheduling - Offer VBAC as an option with a success rate higher than the UC System and the California Maternal Data Center

Commitment Update:
The following activities were completed to support the initial action plan and sustain the achieved milestones. The two mandatory educational sessions were provided to the perinatal staff with 100% participation. Perinatal annual skills day for the second stage of labor algorithm and the perinatal labor support class that includes non-pharmacological interventions to support laboring mothers. The nurses were educated with the use of the peanut ball. Research have shown that the use of a peanut ball may decrease NTSV C-section birth rates. Currently, nurses and physicians are Perinatal Quality Foundation (PQF) certified. The GE Centricity update includes Web Analytics that support fetal heart interpretations utilizing NICHD guidelines. The perinatal annual skills day included the teaching regarding the second stage labor support algorithm that was developed collaboratively with the physicians, with nursing interventions highlighting the repositioning of the patient's position every 30- 60 minutes during the second stage of labor. 100% of the perinatal staff was trained to go through the perinatal labor support class to reinforce the non-pharmacologic nursing interventions that nurses provide during second stage of labor, the peanut ball was introduced to be utilized during the second stage of labor. Evidence have shown that the utilization of the peanut ball may decrease the risk of having a C-section. A nursing policy was developed for the use and maintenance of the peanut ball. Both nursing and physicians are currently Perinatal Quality Foundation (PQF) certified. All new employees are required to have PQF certification. The nursing leadership has purchased an upgrade for the GE Centricity (Software). This will help both nursing and physicians interpretations of the Fetal heart monitoring. The upgrade has tools to support the definitions of the NICHD guidelines in interpreting fetal heart strips.

Your commitment aligns with APSS
11C: Preventing Unnecessary C-Sections - Update

Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
Multidisciplinary learning was highlighted as it takes a team to have a good patient outcome.

Impact Details

Initial Commitment	Commitment Update	Project Next Year
Lives Lost 0	Lives Lost 0	Lives Lost:
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 0
	New Lives Lost (lives lost – actual lives saved) 0

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Preventing VTE View Commitment

Challenge 12B-Preventing Air Embolism View Commitment

Improve Access to Acute Psychiatric Beds View Commitment

Improve Access to Acute Psychiatric Beds - Update - 10.08.19 View Update

UCI Health

Improve Access to Acute Psychiatric Beds – Update – 10.08.19

Contact Info

Name WILLIAM WILSON

Phone: 714-456-6844

Email: wcw@uci.edu

Position: Chief Medical Officer

Organization Name: UCI Health

Commitment Details

Commitment Start Date: 01/01/2018

How many hospitals are represented in this commitment?

Last Report
1

Current
1

Action Plan:
We would like to work with Orange County to optimize downstream placement of patients to appropriate lower levels of care. Unfortunately, more low acute IMD beds (e.g. psychiatric SNF) beds are needed in the community; given that these are not available, a backlog of "boarder" patients is an ongoing challenge which compound ED overcrowding. We communicate closely with our county counterparts in the ED re: daily bed availability; therefore, a bed registry wouldn't be useful at this time. An increased number of hospitals in Orange County are dissolving their LPS designation, shunting more involuntarily detained patients to UCI (which often correlates with severe pathology).

Commitment Update:
UCI is an active participant in the Be Well OC campaign UCI hosted the OC LPS designation meeting March 12, 2019 as part of the county hospital collaborative. We have had meetings with the County to discuss the current status of bed availability at UCI. County case workers are assigned to facilitate discharge planning, although they are often not available. UCI continued presence and involvement with HASC BHS committee.

Your commitment aligns with APSS
Improve Access to Acute Psychiatric Beds

Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
Our continued collaboration with Be Well OC campaign is building networking partners. Our outreach to other facilities when we have open beds has open communication with our counterparts in other organizations. The community as a whole is better focused on the patient obtaining appropriate care. With patience, continued conversations and ongoing collaboration UCI will continue to be a Leader in OC for psychiatric care.

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 0
	New Lives Lost (lives lost – actual lives saved) 0

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Challenge 13B: Optimizing Collaborative Care Planning in Mental Health View Commitment

Challenge 13B: Optimizing Collaborative Care Planning in Mental Health - Update - 10.04.19 View Update

UCI Health

Challenge 13B: Optimizing Collaborative Care Planning in Mental Health – Update – 10.04.19

Contact Info

Name WILLIAM WILSON

Phone: 714-456-6844

Email: wcw@uci.edu

Position: Chief Medical Officer

Organization Name: UCI Health

Commitment Details

Commitment Start Date: 01/01/2018

How many hospitals are represented in this commitment?

Last Report
1

Current
1

Action Plan:
• Provide low barrier ways for staff and patients to collaborate on care planning. o Collaborative care planning begins on admission with nursing  Unit orientation  Community meeting and goal setting each morning  Group therapy schedules  Goals completion / follow up group daily o Collaborative care planning continues on admission day with nursing/ SW/CM and MD in rounds o Improvement opportunity: staff should be in the milieu at all times, only one person at the nurse’s desk.  Improves group attendance, observable patient status and communication on interventions or needs for discharge • Promote patients to take more of an active role in identification and management of symptoms. o In California patients have the right of refusal, which gives choice and active participation it can result in the need for Reise hearings for appropriate treatment o Improvement opportunity: with staff constantly and consistently in the milieu, there is a quicker response to potential escalation where de-escalation can be successful and prn medications given to reduce violent episodes.  Increased awareness and insight on appropriate discharge placement to be communicated to and discussed with interdisciplinary team  Potential decrease LOS  Reduce restraint  Reduce seclusion • Increase patient safety by increasing awareness of and interventions for strong negative emotional states which may precede harm of self or others. o First and foremost the EOC is essential o Ongoing and consistent treatment team meetings and daily team rounds o Initiation of constant observation if warranted or 1:1 if actively suicidal o 15 min safety checks consistently 24/7 with room checks for safety o Thorough room checks when warranted o Improvement opportunity: Staff in the milieu heightens awareness, increases patient interaction, improves overall trust and communication  Potential decreased LOS  Decrease violent episodes  Improve patient satisfaction • Be evaluated with metrics such as Client Satisfaction Surveys, patient lengths of stay, patient readmission rates, Code White frequency, and seclusion room use. o Press Ganey patient satisfaction surveys o HBIPs which include:  SA (Drugs Alcohol Tobacco)  Seclusion and Restraint data

Commitment Update:
Optimization of EMR for; Care planning nursing short and long term goals, HBIPs , suicide screening and assessment.

Your commitment aligns with APSS
Challenge 13B - Collaborative care planning in mental health

Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
Improving the EMR, improves communication through ease of use and improving how we relay the patients story through time

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 0
	New Lives Lost (lives lost – actual lives saved) 0

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Challenge #15: Optimizing Nasogastric Feeding and Drainage Tube Placement and Verification View Commitment

Challenge 16: Optimizing Person and Family Engagement View Commitment

Challenge 16: Optimizing Person and Family Engagement - Update - 10.04.19 View Update

UCI Health

Challenge 16: Optimizing Person and Family Engagement – Update – 10.04.19

Contact Info

Name WILLIAM WILSON

Phone: 714-456-6844

Email: wcw@uci.edu

Position: Chief Medical Officer

Organization Name: UCI Health

Commitment Details

Commitment Start Date: 01/01/2018

How many hospitals are represented in this commitment?

Last Report
1

Current
1

Action Plan:
A new Experience Director is being recruited to focus organizational efforts for both staff and patient engagement and satisfaction. Simultaneously, efforts are underway through the Quality and Safety Oversight Committee to include community patient member(s) who will serve as a voice for the patient's perspective for this committee.

Commitment Update:
The new UCI Experience Director began his role as of October 2018 and has been in place for 6 months with the focus of both staff and patient engagement. The UCI Experience Director has worked with Director of Quality and Safety to recruit a patient/family member for the Quality and Safety Oversight Committee (QSOC). This individual has been selected and has been participating/providing feedback to leadership of the QSOC since March 2019. UCI Health has also recruited and developed a Patient Family Advisory Council (PFAC). The UCI Health Patient Family Advisory Council (PFAC) provides a formal communication pathway for patients and families to take an active role in improving the patient experience, quality and safety at UCI Health. The PFAC focuses on representing the patient voice in providing direct feedback to departments, service lines, programs, and practices throughout UCI Health, so to enhance the experience, quality of care, and safety of every patient and family member. The vision is to achieve a level of care where patients and family involvement is expected and welcome by all. We will accomplish this through collaborative efforts between patients, families, staff, physicians, and administration of UCI Health. The PFAC will consist of at least 12 - 15 patient/family members ideally representing the diversity of UCI Health community. Up to 8 UCI Health staff members also may serve on the PFAC. The first meeting for the UCI Patient Family Advisory Council will be help on April 24th, 2019.

Your commitment aligns with APSS
Challenge 16 - Person and family engagement

Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
We have learned that it takes significant amount of time to recruit and develop a Patient Family Advisory Council (PFAC) to ensure diversity and inclusion of all form of payors that are treated at UCI Health. We have been able to establish this diversity in our PFAC and will better assist with improve the quality, safety and patient experience for all members of the UCI Health patients and surrounding communities. It is extremely important to be highly selective of the candidates for these committees, so that these individuals are dedicated to ensuring that our patients and families have a successful, compassionate, safe, and supported healthcare experience.

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 0
	New Lives Lost (lives lost – actual lives saved) 0

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Parrish Medical Center

Sustaining a Culture of Safety View Commitment

Sustaining a Culture of Safety - Update - 11.20.2019 View Update

Transitions in Caring View Commitment

Transitions in Caring - Update - 12.06.2019 View Update

Air Embolism View Commitment

Reducing Unnecessary Cesarean Sections View Commitment

11A - Postpartum Hemorrage (PPH) View Commitment

Nasogastric Feeding and Drainage Tube Placement and Verification View Commitment

Nasogastric Feeding and Drainage Tube Placement and Verification - Update - 11.20.2019 View Update

APSS 18 - Post-operative Delirium in Older Adults View Commitment

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

FAILURE TO RESCUE: MONITORING FOR OPIOID INDUCED RESPIRATORY DEPRESSION - Update - 11.11.2019 View Update

Airway Safety View Commitment

Airway Safety - Update - 11.20.2019 View Update

Sepsis View Commitment

Sepsis - Update - 11.11.2019 View Update

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

SSI – Surgical Site Infection for COLO and HYST procedures - Update - 11.27.2019 View Update

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

VAE/IVAC – Ventilator Associated Event w/infection - Update - 11.27.2019 View Update

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 - 12.06.18 View Update

Parrish Medical Center

Distribution of “Baby Boxes” to decrease the incidence of co-bedding and SIDs deaths – Update – 12.06.18

Contact Info

Name edwin loftin

Phone: 321-268-6120

Email: edwin.loftin@parrishmed.com

Position: VP Acute Care/ CNO

Organization Name: Parrish Medical Center

Commitment Details

Commitment Start Date: 05/23/2016

How many hospitals are represented in this commitment?

Last Report
1

Current
1

Action Plan:
1. 800 new Baby Boxes have been donated by the Jess Parrish Foundation for distribution in 2017 & 2018 2. Baby Boxes continue to be distributed to every family since it’s initiation on May 23, 2016. 3. We will continue to investigate additional funding sources for future purchases of the Baby Boxes and supplies. 4. County wide stats continue to be monitored for effect on SIDS deaths. 5. Distribution of "Baby Boxes" to decrease the incidence of co-bedding and SIDs deaths poster presentation at the annual FPQC conference in April 2018 6. Explore funding options – Approval to receive co-grant from The Parrish Foundation and the Parrish Physicians Group for 2019

Commitment Update:
All families of Newborns delivered at Parrish Medical Center will be given a no-cost, Baby Box with education on its use, and reinforcement of the evidence which recommends babies sleep on a firm surface, without pillows, blankets and toys or in an adult's bed - that can smother them.

Your commitment aligns with APSS
Other

Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
See original 2018 commitment

Impact Details

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

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Patient Safety Curriculum - APSS #17 View Commitment

Critical Congenital Heart Disease Screening in Newborns View Commitment

Critical Congenital Heart Disease Screening in Newborns - Update - 11.27.2019 View Update

Pediatric Adverse Drug Events View Commitment

Pediatric Adverse Drug Events - Update - 11.20.2019 View Update

Hand Hygiene View Commitment

Hand Hygiene - Update - 11.20.2019 View Update

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

Maintain Zero Hospital-Acquired Stage III and IV Pressure Ulcers - Update - 12.06.18 View Update

Parrish Medical Center

Maintain Zero Hospital-Acquired Stage III and IV Pressure Ulcers – Update – 12.06.18

Contact Info

Name edwin loftin

Phone: 321-268-6120

Email: edwin.loftin@parrishmed.com

Position: VP Acute Care/ CNO

Organization Name: Parrish Medical Center

Commitment Details

Commitment Start Date: 08/01/2016

How many hospitals are represented in this commitment?

Last Report
1

Current
1

Action Plan:
The Leadership of PMC is committed to supporting the Pressure Ulcer Prevention effort, our care partners and Medical Staff as we strive to maintain our culture of patient safety. PMC maintains a supply of pressure reduction mattress replacements on site. This a nurse driven initiative which allows the staff to quickly provide intervention for patients with PU or who are at a high risk for development of PU. Quarterly prevalence surveys are completed and the data reported to NDNQI in addition to random surveillance of documentation for accuracy and compliance. Weekly check-in meetings with senior staff are used to review risk and identify deficiencies for early intervention. Evaluation of new hospital beds and support surfaces is complete. Additions to the PUP team are planned with the enhanced education to identify patients at risk and mitigate patient injury from pressure related occurrences. Improvements to the EMR are monitored to enhance nurse compliance and ease of charting

Commitment Update:
Maintenance will be dependent on continued attention and a diligent focus from all levels to rapidly identify patients admitted with a PU. Specially educated nurses provide a resource on the hospital floors to consult with regarding HAPU prevention and treatment. They participate in data collection for NDNQI monitoring for compliance with hospital policy and procedures. The solutions Algorithms for Skin and Wound Care is a guideline detailing plan of care and treatment options for wounds and is provided to each unit for easy reference and access to the staff. New products such as skin barriers, support surfaces and pressure relieving devices are undergoing review for efficacy. In-services and reviews on product used are provided to staff to maintain competencies as needed. These efforts are coordinated and monitored by the CWON Coordinator

Your commitment aligns with APSS
Other

Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
See original 2018 commitment.

Impact Details

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

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Zero Falls with injury for our patients View Commitment

Zero Falls with injury for our patients - Update - 11.20.2019 View Update

Medication Errors View Commitment

Medication Errors - Update - 12.06.2019 View Update

CAUTI-Indwelling Catheter Associated Urinary Tract Infection View Commitment

CAUTI-Indwelling Catheter Associated Urinary Tract Infection - Update - 11.27.2019 View Update

CLABSI-Central Line Associated Bloodstream Infection View Commitment

CLABSI-Central Line Associated Bloodstream Infection - Update - 11.27.2019 View Update

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 - 11.20.2019 View Update

Antimicrobial Stewardship View Commitment

Antimicrobial Stewardship - Update - 11.20.2019 View Update

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 - 11.20.2019 View Update

Neonatal Oxygen Targeting View Commitment

Neonatal Oxygen Targeting - Update - 11.27.2019 View Update

Anemia and Blood Transfusions View Commitment

Anemia and Blood Transfusions - Update - 11.20.2019 View Update

Venous Thromboembolism (VTE) View Commitment

Venous Thromboembolism (VTE) - Update - 10.03.2019 View Update

Access To Acute Psychiatric Beds View Commitment

Access To Acute Psychiatric Beds - Update - 11.27.2019 View Update

Resuscitation Optimization View Commitment

Resuscitation Optimization - Update - 11.11.2019 View Update

Changhua Christian Hospital

Changhua

Airway Safety View Commitment

Airway Safety - Update - 09.02.18 View Update

Changhua Christian Hospital

Airway Safety – Update – 09.02.18

Contact Info

Name Samuel Chang

Phone: +886 4 7238595#8455

Email: 60452@cch.org.tw

Position: deputy Quality and Safety director

Organization Name: Changhua Christian Hospital

Commitment Details

Commitment Start Date: 07/01/2017

How many hospitals are represented in this commitment?

Last Report
1

Current
1

Action Plan:
Improve Airway Safety (1)Difficult Intubation Assessment; This will be assessed according to criteria related to throat, neck trauma, infection, surgery, obesity, or assessing history of difficult intubation. (2)OSCE Training Program and Outcome, also known as Rapid Sequence intubation training and emergency cricothyrotomy (3)Mobile Intubation Car with all Requirements for Difficult (4)Intubation and Resuscitation Services; Anesthesia physicians will support difficult intubation and ENTs, thoracic surgery physicians will support emergency cricothyrotomy.

Commitment Update:
We organize OSCE committee to implement training program and audit operation process. Physician, intern and registered nurse include training program are above 90% certified rate. The successful rate of cricothyrotomy within 2 times improve from 79% to 87%. Following airway safety guideline, keep patient more safety and efficiency.

Your commitment aligns with APSS
Challenge 8A - Safer airway management

Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
Best practice learn from Actionable Patient Safety Solution (APSS) #8A:SAFER AIRWAY MANAGEMENT. The valuable lessons is we organize OSCE committee to implement training program and audit operation process.

Impact Details

Initial Commitment	Commitment Update	Project Next Year
Lives Lost 2400	Lives Lost 2400	Lives Lost: 2319
Lives Spared Harm Target 90	Actual Lives Spared Harm in last 12 months 81	Lives Spared Harm Target for following calendar year 90
Lives Saved Target 90	Actual Lives Saved in last 12 months (might differ from initial target) 81	Projected Target of Lives Saved for following calendar to try to finish commitment 90
	New Lives Lost (lives lost – actual lives saved) 2319

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Healthcare-associated Infections (HAIs) View Commitment

Healthcare-associated Infections (HAIs) - Update - 09.02.18 View Update

Changhua Christian Hospital

Healthcare-associated Infections (HAIs) – Update – 09.02.18

Contact Info

Name Samuel Chang

Phone: +886 4 7238595#8455

Email: 60452@cch.org.tw

Position: deputy Quality and Safety director

Organization Name: Changhua Christian Hospital

Commitment Details

Commitment Start Date: 07/01/2017

How many hospitals are represented in this commitment?

Last Report
1

Current
1

Action Plan:
Reduce Healthcare-associated Infections (HAIs): (1) Health care–associated infection risks, rates, and trends are tracked quarterly by the infection committee. (2)Processes are redesigned based on risk, rate, and trend data and information. (3)Assesses the infection control risks at least annually and takes action to focus or refocus the infection prevention and control program.

Commitment Update:
As urinary tract infection (UTI), we refer evidence to alter Foley size from 16 Fr. To 14Fr. for general drain urine condition to mitigate harm for urine tract. We also introduce bladder scan to detect urine volume in bladder and help physician to assess whether or not remove Foley. The UTI rate improves from 0.72% to 0.48%

Your commitment aligns with APSS
Challenge 2 - Healthcare-associated Infections (HAIs)

Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
Best practice learn from Sunnybrook Health Sciences Centre, Medical Directive for Early Removal of Urinary Catheter’s in Medical Ward Patients. 2015. We introduce some medical device to improve UTI.

Impact Details

Initial Commitment	Commitment Update	Project Next Year
Lives Lost 2400	Lives Lost 2400	Lives Lost: 2306
Lives Spared Harm Target 90	Actual Lives Spared Harm in last 12 months 94	Lives Spared Harm Target for following calendar year 95
Lives Saved Target 90	Actual Lives Saved in last 12 months (might differ from initial target) 94	Projected Target of Lives Saved for following calendar to try to finish commitment 90
	New Lives Lost (lives lost – actual lives saved) 2306

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Creating a Culture of Safety View Commitment

Creating a Culture of Safety - Update - 09.02.18 View Update

Changhua Christian Hospital

Creating a Culture of Safety – Update – 09.02.18

Contact Info

Name Samuel Chang

Phone: +886 4 7238595#8455

Email: 60452@cch.org.tw

Position: deputy Quality and Safety director

Organization Name: Changhua Christian Hospital

Commitment Details

Commitment Start Date: 07/01/2017

How many hospitals are represented in this commitment?

Last Report
1

Current
1

Action Plan:
Create a Culture of Safety: (1)Acknowledgment of the high-risk nature of a hospital’s activities and the determination to achieve consistently safe operations (2)Individuals are able to report errors or near misses without fear of reprimand or punishment; (3)Encouragement of collaboration across ranks and disciplines to seek solutions to patient safety problems (4)Resources, such as staff time, education, a safe method for reporting issues, and the like, to address safety concerns.

Commitment Update:
We refer evidence Patient Safety Culture Improvement Tool to implement the following activity 1.Team Work – Collaborative disciplines 2.Patient Safety Leader Education and Training 3. Patient Safety Leader Performance Evaluation 4.Workload Management 5.Fatigue Management 6.Incident Sharing and Leaning 7.Incident Disclosure 8.Safety Risk Analysis System We conduct patient safety culture survey and improve from 67.9% to 74.1%.

Your commitment aligns with APSS
Challenge 1 - Culture of safety

Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
Best practice learn from the Actionable Patient Safety Solution (APSS) #1:CULTURE OF SAFETY. We conduct patient safety culture survey and improve from 67.9% to 74.1%.

Impact Details

Initial Commitment	Commitment Update	Project Next Year
Lives Lost 2400	Lives Lost 2400	Lives Lost: 2308
Lives Spared Harm Target 90	Actual Lives Spared Harm in last 12 months 92	Lives Spared Harm Target for following calendar year
Lives Saved Target 90	Actual Lives Saved in last 12 months (might differ from initial target) 92	Projected Target of Lives Saved for following calendar to try to finish commitment 90
	New Lives Lost (lives lost – actual lives saved) 2308

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Hand-off Communications View Commitment

Hand-off Communications - Update - 09.02.18 View Update

Changhua Christian Hospital

Hand-off Communications – Update – 09.02.18

Contact Info

Name Samuel Chang

Phone: +886 4 7238595#8455

Email: 60452@cch.org.tw

Position: deputy Quality and Safety director

Organization Name: Changhua Christian Hospital

Commitment Details

Commitment Start Date: 07/01/2017

How many hospitals are represented in this commitment?

Last Report
1

Current
1

Action Plan:
Promote Hand-off Communications (1) Standardized critical content is communicated between health care practitioners during handovers of patient care. (2) Standardized forms, tools, or methods support a consistent and complete handover process (3) Data from adverse events resulting from handover communications are tracked and used to identify ways in which handovers can be improved, and improvements are implemented.

Commitment Update:
We introduce ISBAR skill as standardized critical content is communicated between health care practitioners during handovers of patient care and implement “ticket-to-ride” handover sheet as standardized forms, tools, or methods support a consistent and complete handover process. We build handover information system to offer more convenient and correct information to handover process and improve compliance rate from 88% to 97%.

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

Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
Best practice learn from Actionable Patient Safety Solution APSS #6: HAND-OFF COMMUNICATIONS. We build handover information system to offer more convenient and correct information to handover process and improve compliance rate from 88% to 97%.

Impact Details

Initial Commitment	Commitment Update	Project Next Year
Lives Lost 2400	Lives Lost 2400	Lives Lost: 2308
Lives Spared Harm Target 90	Actual Lives Spared Harm in last 12 months 92	Lives Spared Harm Target for following calendar year
Lives Saved Target 90	Actual Lives Saved in last 12 months (might differ from initial target) 0	Projected Target of Lives Saved for following calendar to try to finish commitment 90
	New Lives Lost (lives lost – actual lives saved) 2308

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Central Line-associated Blood Stream Infections (CLABSI) View Commitment

Medication Errors View Commitment

Antimicrobial Stewardship View Commitment

Severe Hypoglycemia View Commitment

Patient Blood Management View Commitment

Unplanned Extubation View Commitment

Early Detection and Treatment of Sepsis for High-income Countries View Commitment

Systematic Prevention and Resuscitation of In-hospital Cardiac Arrest View Commitment

Postpartum Hemorrhage (PPH) View Commitment

Severe Hypertension in Pregnancy and Postpartum View Commitment

Reducing Unnecessary Cesarean Sections (C-Sections) View Commitment

Venous Thromboembolism (VTE) View Commitment

Falls and Fall Prevention View Commitment

Nasogastric Tube (NGT) Placement and Verification View Commitment

Person and Family Engagement View Commitment

Air Embolism View Commitment

Patient Safety Curriculum View Commitment

Post-Operative Delirium in Older Adults View Commitment

Monitoring for Opioid-induced Respiratory Depression View Commitment

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

Failure to detect critical congenital heart disease (CCHD) - Update - 09.02.18 View Update

Changhua Christian Hospital

Failure to detect critical congenital heart disease (CCHD) – Update – 09.02.18

Contact Info

Name Samuel Chang

Phone: +886 4 7238595#8455

Email: 60452@cch.org.tw

Position: deputy Quality and Safety director

Organization Name: Changhua Christian Hospital

Commitment Details

Commitment Start Date: 10/01/2017

How many hospitals are represented in this commitment?

Last Report
1

Current
1

Action Plan:
● Implement a plan that includes fundamentals of change outlined in the National Quality Forum safe practices,including awareness, accountability, and action. ● Hospital governance and senior administrative and medical and nursing leadership commit to become aware of this major performance gap in their own healthcare system. ● Hospital governance, senior administrative leadership, and clinical/safety leadership close their own performance gap by implementing a comprehensive approach to addressing the performance gap ● Set a goal date to implement the plan to address the gap with measurable quality indicators. ● Allocate a budget for the plan to be evaluated by governance boards and senior administrative leaders. ● Clinical/safety leadership endorse the plan and drive implementation across all providers and systems. ● Conduct data collection and analysis to be used for implementation and assessment of outcomes

Commitment Update:
In the “Failure to Detect CCHD” program, we have established a pre-discharge blood oxygen concentration screening process for newborns, and designed a check list to provide information of screening data to parents. In addition, education and training for physicians and nursing staff in the baby room have been established. Everyone is familiar with this screening activity. Hence this screening has already started in mid-August.

Your commitment aligns with APSS
Challenge 7B - Detecting critical congenital heart disease (CCHD) in newborns

Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
Best practice learn from Actionable Patient Safety Solution (APSS) for #7B:FAILURE TO DETECT CRITICAL CONGENITAL HEART DISEASE (CCHD) IN NEWBORNS. The valuable lessons is established a pre-discharge blood oxygen concentration screening process for newborns, and designed a check list to provide information of screening data to parents.

Impact Details

Initial Commitment	Commitment Update	Project Next Year
Lives Lost 48	Lives Lost 48	Lives Lost: 45
Lives Spared Harm Target 4	Actual Lives Spared Harm in last 12 months 3	Lives Spared Harm Target for following calendar year 4
Lives Saved Target 4	Actual Lives Saved in last 12 months (might differ from initial target) 3	Projected Target of Lives Saved for following calendar to try to finish commitment 4
	New Lives Lost (lives lost – actual lives saved) 45

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CHOC Children's Hospital

8B - Unplanned Extubations in Children View Commitment

8A - Safer Airway Management View Commitment

"We aspire to partner with children and families to deliver what matters to them" View Commitment

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

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

Preventing Patient Deterioration View Commitment

Preventing Patient Deterioration - Update - 10.15.18 View Update

CHOC Children's Hospital

Preventing Patient Deterioration – Update – 10.15.18

Contact Info

Name James Cappon

Phone: (714) 509-8590

Email: jcappon@choc.org

Position: Chief Quality Officer

Organization Name: CHOC Children's Hospital

Commitment Details

Commitment Start Date: 01/01/2013

How many hospitals are represented in this commitment?

Last Report
1

Current
1

Action Plan:
Active interventions included: 1) the development of a Rapid Response Team, to bring critical care assistance to the bedside of a worsening non-ICU patient, which included the ability of patient families to call for such help; 2) proactive identification and night time rounding on patients felt to be most at risk; and 3) the implementation of a Pediatric Early Warning System (PEWS), in which all non-ICU patients are monitored for standardized physiological status and that status is continuously displayed on unit electronic whiteboards and in the EHR for local and/or remote viewing.

Commitment Update:
The CHOC Children's program to reduce non-ICU resuscitations quickly expanded backward in time to identify children in earlier and earlier stages of clinical deterioration. This primarily occurred via the serial implementation in Years 1 and 2 of a Rapid Response Team (RRT) and Pediatric Early Warning System (PEWS), respectively. Subsequently, family members were brought into the fold and educated at patient admission that they could initiate RRTs of their own accord. The most important change, however, was that of culture, where hospital staff of all levels came to find non-detected and/or non-escalated patient deterioration as fundamentally unacceptable, which further advanced the pace, breadth and intensity of all efforts. The gratifying overall result is that the CHOC Non-ICU Code Rate dropped approximately 85% in the first two years of the program and has remained at that low level for the past 10 years. This means that hundreds of children have avoided preventable respiratory, cardiac and neurologic arrests. Moreover, millions of dollars of unnecessary healthcare costs have been avoided.

Your commitment aligns with APSS
1 (Culture of Safety), 4 (Failure to Rescue), 9 (Early Detection of Sepsis)

Please describe any best practices your organization has learned through your commitment and share valuable lessons or challenges that were overcome
Changing culture to a state in which early detection of and response to deterioration are the only acceptable workflows is the key to success. So built-in is this mentality that even a small blip in our Non-ICU Code Rate leads to considerable investigation and process improvement. The past year, for example, led to the development of and initiation of a "Watcher Program," where patients who have subtle changes, perhaps even prior to their PEWS score changing and/or well-before meeting RRT criteria, are identified as "Watchers," or children bearing watching. A bedside multidisciplinary huddle (including family) is initiated, a mitigation plan created, and a follow up done at 2 hours to see if the desired outcomes have been achieved. Early results show an increase in RRTs, a decrease in RRTs requiring ICU transfer, and a reduction in Non-ICU Code Rate.

Impact Details

Initial Commitment	Commitment Update	Project Next Year
Lives Lost 0	Lives Lost 0	Lives Lost: -45
Lives Spared Harm Target 0	Actual Lives Spared Harm in last 12 months 51	Lives Spared Harm Target for following calendar year 48
Lives Saved Target 0	Actual Lives Saved in last 12 months (might differ from initial target) 45	Projected Target of Lives Saved for following calendar to try to finish commitment
	New Lives Lost (lives lost – actual lives saved) 0

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Challenge 2B - CAUTI Prevention View Commitment

Challenge #2A: Hand Hygiene View Commitment

APSS #9: Early Detection and Treatment of Sepsis View Commitment

APSS #10: Reducing Non-ICU Codes View Commitment

APSS #12A: Venous Thromboembolism (VTE) View Commitment

APSS #13: Mental Health View Commitment

APSS #14: Falls & Fall Prevention View Commitment

APSS #4: Monitoring for Opioid Induced Respiratory Depression View Commitment

APSS #5: Anemia and Transfusions View Commitment

APSS #2F: CLABSI View Commitment

APSS #6: Hand-off Communications View Commitment

APSS #7A: Optimal Neonatal Oxygen Targeting View Commitment

APSS #15: NG Tube Placement and Verification View Commitment

APSS #1: Creating a Culture of Safety View Commitment

CENTRO MEDICO “LIC. ADOLFO LÓPEZ MATEOS”

Estado de México

Adopción y Adaptación de un Protocolo de Prevención y Detección Oportuna de Tromboembolismo Venoso en el Paciente Quirúrgico y no Quirúrgico. View Commitment

Diseño de un Programa de Capacitación Continúa en la Formación de Seguridad del Paciente Durante el Internado Médico y Residencias Médicas. View Commitment

Implementación de un Algoritmo para la Identificación, Instalación y Mantenimiento de Vía Aérea. View Commitment

Manejo de la Sangre View Commitment

FORTALECIMIENTO DE LA CULTURA DE SEGURIDAD DEL PACIENTE EN EL SERVICIO DE URGENCIAS View Commitment

Difusión e implantación del paquete de control de las Bacteremias Asociadas a Catéter Venoso Central. View Commitment

Diseño e implementación de un Sistema de notificación de errores de Medicación View Commitment

Implementación de un Protocolo de Prevención de la Depresión Respiratoria inducida por Opioides. View Commitment

Implementación de un Programa de Involucramiento del Paciente y Familia (PFE). View Commitment

Disminución de la Prevalencia Cruda de Lesiones por Presión Originada en Pacientes Hospitalizados. View Commitment

Implementación de un Proceso Multidisciplinario ara la Instalación, Mantenimiento y Retiro de Sonda Vesical. View Commitment

Reforzar la estandarización del Proceso de valoración, intervención, evaluación y reevaluación para eliminación de secreciones Traqueobronquiales en pacientes con cánula oro traqueal. View Commitment

Falta de apego a las medidas de higiene por personal médico y de enfermería para el cuidado, control y aspiración de secreciones bronquiales en los pacientes con ventilación mecánica. View Commitment

Rediseño y estandarización del procedimiento para la de instalación, verificación, vigilancia y retiro de la Sonda Nasogástrica View Commitment

Fortalecimiento del Programa Permanente de Vigilancia del Uso de Antimicrobianos (Antimicrobial Stewardship) View Commitment

Implementación de un Programa de Detección Temprana y Tratamiento de Sepsis View Commitment

Implementación de un Plan de Atención Colaborativa para la Detección y Manejo de pacientes en Salud Mental. View Commitment

Elevar el porcentaje de apego a la Higiene de Manos View Commitment

Implementación de un Programa de Prevención Sistemática y Reanimación en Paro Cardiaco. View Commitment

Identificación oportuna del Delirio Post operatorio en Adultos Mayores. View Commitment

Infecciones del Tracto Urinario Asociado a Catéteres (CAUTI) View Commitment

ATENCIÓN Y REPERFUSIÓN DE PACIENTES, ENFERMEDAD VASCULAR CEREBRAL TIPO ISQUEMICA View Commitment

Hospital Español

Mexico City

Hand Hygiene Improvement View Commitment

Hand Hygiene Improvement - Update - 12.31.2019 View Update

Development of a incident reporting system for notification and analysis of adverse events associated with medical care. View Commitment

Development of an Incident Reporting System for Notification and Analysis of Adverse Events Associated with Medical Care. - Update - 12.29.2019 View Update

Prevention of Venous Thromboembolism in Hospitalized Patients View Commitment

Prevention of Venous Thromboembolism in Hospitalized Patients - Update - 12.24.2019 View Update

Improving the Safety of Airway Management View Commitment

Improving the Safety of Airway Management - Update - 12.28.2019 View Update

Fall Risk Prevention in Hospitalized Patients View Commitment