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Posterboard Number:
261
Organization Name:
NCH Healthcare System
Contact Name:
Catherine Ravelo
Contact Email:
catherine.ravelo@nchmd.org
Description:
The NICU team wanted to implement safe sleep practices while the NICU baby was still hospitalized according to AAP and NANN guidelines. Recognizing that parents learn how to handle their babies by watching the staff’s actions leading by example and educating families would decrease risks of SIDS after discharge.
Aim:
Achieve 100% compliance of safe sleep positioning of eligible babies in the NICU
Actions Taken:
Staff and family education regarding safe sleep settings for SIDS prevention conducted. Laminated bedside visual cues were implemented at all bedsides with babies 34 weeks and older in open cribs. Parent handouts at discharge supporting continued safe sleep compliance for the home setting.
Summary of Results:
Demonstrated upward trend of safe sleep compliance initially 18% to 60%, staff education expanded to the entire department (August 2012) including well baby and NICU staff with bedside visual cues utilized. Department compliance spot surveys showed 100% compliance with safe sleep criteria in NICU eligible patients September 2012
Track(s):
Get Results
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Posterboard Number:
362
Organization Name:
The Joint Commission
Contact Name:
Patricia Adamski
Contact Email:
padamski@jointcommission.org
Description:
Strategies to help organizations focus patient safety and compliance initiatives and improve outcomes are provided along with the incorporation of the tools and resources that are available on The Joint Commission website and through Joint Commission Connect.
Aim:
To assist organizations in making the most of their compliance and patient safety initiatives
Actions Taken:
Ensuring patient safety and quality of care can be supported and achieved by compliance with Joint Commission Standards (which also incorporate the Medicare Conditions of Participation) and National Patient Safety Goals. Looking at issues in isolation can cause additional issues and costs.
Summary of Results:
By establishing a framework for compliance and safety efforts, staff, physicians and licensed independent practitioners can learn the expectations and can become partners in these critical initiatives which in turn improves safety and outcomes for the patients your organization serves.
Track(s):
Get Results
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Posterboard Number:
62
Organization Name:
Counties Manukau District Health Board
Contact Name:
Diana Dowdle
Contact Email:
Diana.dowdle@middlemore.co.nz
Description:
Counties Manukau Health has identified the need to anticipate and prevent acute health problems and to respond promptly and effectively in the community when acute problems occur, thereby avoiding admissions to hospital and providing timely and safe care to any people needing in-hospital care.
Aim:
To give back to our community 20,000 well days by reducing hospital bed days
Actions Taken:
The 20,000 Days Campaign was launched in May 2012 and sustained through the IHI Breakthrough Series Collaborative improvement programme which supports the implementation of best practices across eigth key intervention areas. Thirteen collaborative teams have been established, each with aims to contribute to the goal for the 20,000 Days Campaign
Summary of Results:
Each of the Collaborative teams have developed measurement dashboards which will monitor the results of the improvements made. A high level measurement dashboard for the whole system is reported monthly and to date 8194 days have been saved since June 2011.
Track(s):
Innovate
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Posterboard Number:
197
Organization Name:
Lucile Packard Children's Hospital
Contact Name:
Danielle Scapa
Contact Email:
dscapa@LPCH.org
Description:
NICU layout does not support workflow. Space is cramped and lacks standards. RN’s cannot find necessary items. RN’s must leave bedside many times for supplies.
Frustration levels are high. Attention taken away from the patient
Layout different in each room
Aim:
Develop and implement a layout that supports patient care workflow
Actions Taken:
A series of 5S workshops
The first workshop was used as the model room to develop a standard layout. Then replicated to each of the other three patient care rooms.
After each event the team reflected on lessons learned and applied them to the next event.
Summary of Results:
With various setbacks, two NO GO calls, and many rounds of trial and error the unit still achieved big wins. Wins not just in time saved and travel distance, but in the beginnings of an environment that encourages, supports, and enables continuous improvement at all levels.
Track(s):
Motivate
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Posterboard Number:
424
Organization Name:
Vancouver Island Health Authority
Contact Name:
Martin Wale
Contact Email:
martin.wale@viha.ca
Description:
Successful quality and patient safety infrastructure requires an effective quality oversight system. This Vancouver Island Health Authority (VIHA) addressed this need by creating a Combined Quality System (CQS). This CQS brings together organizational and medical quality functions to provide a quality oversight system and facilitate access to decision-makers.
Aim:
VIHA’s CQS creates synergy and reduces duplication between organizational and medical quality functions.
Actions Taken:
This new system is centred on a Combined Quality Council, with members drawn from organizational and medical stakeholders, sitting between the Executive Management Committee, senior operational management, and the Health Authority Medical Advisory Committee. These entities work through shared organizational and medical accountability for the common domain of quality.
Summary of Results:
VIHA’s CQS is an effective “operating system” for quality, resulting in specific improvements, including: 1) local Quality Committees address local issues; 2) forum now exists for cross-cutting quality issues; 3) centralized flow of information related to quality, disseminated through the CQC Secretariat to promote learning and dissemination of good practice.
Track(s):
Get Results
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Posterboard Number:
98
Organization Name:
Excela Health Latrobe Hospital
Contact Name:
Joan Grote
Contact Email:
jgrote@excelahealth.org
Description:
Surgical site infections (SSI) represent a significant cause of morbidity and mortality for patients, resulting in increased utilization of hospital resources and increased costs of health care. Over a 5-year period, we noted a progressive rise in the incidence of neurosurgical SSI, peaking at 17 infections in CY 2010.
Aim:
We sought to eliminate neurosurgical SSI at our hospital.
Actions Taken:
Multidisciplinary team
RCA of all infections
Extensive education of medical and nursing staff
Extensive patient education materials for pre-op and post-op care
Pre-operative screening for Staph aureus
Mupirocin decolonization for carriers
CHG bathing x5 days pre-operatively
CHG imprgenated cloths
CHG/alcohol surgical prep
Weight-based antibiotic prophylaxis
Monthly compliance review
Summary of Results:
For CY 2011 only 4 neurosurgical SSI noted (76% reduction).
January-June 2012 there were 0 infections identified.
Lessons learned:
Multidisciplinary teams are essential.
Continuous surveillance and process improvement work.
"Low tech" solutions and continuous education can facilitate high volume
outcomes.
Sustained eliminaion of neurosurgical SSI is attainable.
Track(s):
Get Results
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Posterboard Number:
189
Organization Name:
Ko Awatea
Contact Name:
Suzanne Proudfoot
Contact Email:
suzanne.proudfoot@middlemore.co.nz
Description:
The Health Quality & Safety Commission (HQSC) entered into a partnership with Counties Manukau District Health Board (CMDHB) via Ko Awatea to facilitate a national programme to “Prevent Central Line Associated Bacteraemia (CLAB). This 18 month programme commenced in October 2011 and is planned to continue to April 2013.
Aim:
Reduce the CLAB rate in New Zealand ICUs to <1/1000 line days
Actions Taken:
Engagement of ALL 20 District Health Boards (DHBs); Change Package prepared, How to Guide developed, ICU line insertion checklist and maintenanace checklists modified to incorporate the local DHB needs. Central line insertion pack was developed, with modifications for the Neonatal unit. Extranet data base activated. Collaboartive methodology implemented
Summary of Results:
Reduction of national CLAB rate from 3.32/1000 to 0.30/1000 line days
ZERO CLAB nationally for April, May & August. Engagement with ALL 20 District Health Boards, Strengthening of regional networks, Agreed operational data definitions and key processes. Developed an insertion pack. Increased Capacity and Capability in the implementation of MFI
Track(s):
Get Results
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A National Collaborative
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Posterboard Number:
310
Organization Name:
Public Health Wales (1000 Lives Plus)
Contact Name:
Alan Willson
Contact Email:
Alan.Willson@wales.nhs.uk
Description:
Uniquely, Wales has a national IHI Open School Chapter. It is aligned to national policy through the 1000 Lives Plus country-wide improvement programme. It accelerates multi-professional student engagement in national improvement priorities across all universities in Wales and promotes a consistent methodology across education and practice.
Aim:
Accelerating student engagement in the improvement methodology used by healthcare professionals through 1000 Lives Plus.
Actions Taken:
1. Alignment with national improvement priorities and recognised in Welsh Government policy.
2. Including multi-professional students in country-wide improvement programme.
3. Students access national events, resources, social media, teaching and training.
4. Standardised approach to improvement for students and service.
5. Engagement of educators to support a culture of improvement.
Summary of Results:
• 2000+ members
• 100+ students attend national and collaborative events
• 104 educators supporting students in improvement
• 7 student improvement projects
• Students creating local hubs.
Challanges:
• Sustainability as active students graduate.
• More local student-led initiatives needed.
• Increasing social media engagement.
• Increasing faculty involvement.
Track(s):
Student
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Posterboard Number:
129
Organization Name:
Greenwich Hospital
Contact Name:
Mark Chrostowski
Contact Email:
mark.chrostowski@greenwichhospital.org
Description:
Through a collaborative multidisciplinary effort, we successfully designed, implemented, monitored, and continually improved our management of pain for patients undergoing joint replacement surgery. Patients are using less opioids and are having less opioid related side effects. The protocol also seems to facilitate physical therapy, rehabilitation and discharge from hospital.
Aim:
Design an evidenced based multimodal protocol to improve pain after joint replacement surgery
Actions Taken:
Instead of exclusively utilizing opioids, a multimodal approach was developed using acetaminophen, celecoxib, gabapentin, local anesthetics, intra-operative ketamine and dexamethasone. Emphasis was placed on preventative analgesia to begin treating pain before it starts. We encouraged all healthcare providers to standardize their clinical practice based on these evidenced based protocols.
Summary of Results:
Compared to historical controls, the patients receiving the new protocol required 40% less opioids during their entire hospital stay. We also noticed a decrease in opioid related side effects. Incidence of nausea and vomiting decreased by 49% and 54%, respectively. Pruritis decreased by 97%. Urinary retention decreased by 73%.
Track(s):
Get Results
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Posterboard Number:
280
Organization Name:
North Shore University Hospital
Contact Name:
Dana Lustbader
Contact Email:
Lustbader@nshs.edu
Description:
North Shore University Hospital is an 800-bed hospital within a fifteen
hospital not-for-profit health care system in the New York metropolitan area.The Palliative Care Program, which includes a 10-bed in-patient unit was started in 2005. The organization received Joint Commission Certification in 2012.
Aim:
Describe the process for acheiving Joint Commission Certification
Actions Taken:
The program partnered with Quality Management and engaged the entire organization in a process to review all standards and best practices and have meaningful discussions about performance improvement. We worked across disciplines to come to consensus about shared competencies and vision for the program.
Summary of Results:
The site visit itself added value to the program by engaging the organization's leadership and giving the staff an opportunity to describe their successes and innovations. The process strengthened the performance improvement program and collaboration with the Quality Management department. The site visitor made helpful suggestions which were implemented.
Track(s):
Motivate
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