Organization Name: MedStar Washington Hospital Center
Contact Name: Sally Gutierrez RN MSN
Contact Email: sally.b.gutierrez@medstar.net

Aim:
Develop a standardized and reliable process of identifying at risk patients with sepsis

Actions Taken:
Education on severe sepsis /septic shock was instituted. Education emphasized the rapid progression of severe sepsis to organ dysfunction and death in the event of delayed care. Bedside nurses were trained and empowered to obtain lactate levels in patient in whom infection is known or suspected. Physicians implement EGDT.

Summary of Results:
The mortality rate decreased from 40.47% at baseline to 36.98% during the period of intervention, with a further decline to 29.90% at 2 months post study intervention.

Track(s):
Patient Safety

Organization Name: Community Medical Center
Contact Name: Donna Cetroni
Contact Email: dcetroni@barnabashealth.org

Aim:
Reduce rate of elective deliveries >37 and <39 weeks from 38% in 2010 to zero.

Actions Taken:
Comprehensive analysis conducted using concurrent and retrospective review methods. Focused on accurate documentation and appropriate coding. Physicians observed for variability in practice and adherence to guidelines. Scheduling standardized and collaborative practice was adopted. Check-list developed to evaluate appropriateness and a hard stop policy was implemented at the time of scheduling.

Summary of Results:
There was significant decrease in the practice of elective deliveries prior to 39 weeks from 38% in 2010 to 0% year-to-date 2013. As the result of several process modifications/additions, the team identified several issues. Improvements in coding, documentation, scheduling, and obstetrical practice significantly reduced elective deliveries prior to 39 weeks.

Track(s):
Patient Safety

Organization Name: Sarasota Memorial Hospital
Contact Name: Renee Maietta
Contact Email: jennifer-sweeney@smh.com

Aim:
Provide challenging patient simulations to develop critical thinking skills, learn teamwork, and increase self-confidence.

Actions Taken:
Short critical care events are simulated in-situ utilizing a huddle format with pre-briefing, process review, and debriefing focused on patient safety. Sim Huddles are limited to 10 minutes to avoid disruption to actual patient care. Evaluation forms are collected and results are reviewed with the staff at a later time.

Summary of Results:
Implementation of this practice change resulted in a higher level of staff preparedness and confidence contributing to optimal outcomes when emergencies arise. Every “Sim Huddle” has uncovered at least one latent safety threat, be it an equipment or process issue, that is then immediately corrected further supporting safety and preparedness.

Track(s):
Patient Safety

Organization Name: London Health Sciences Centre
Contact Name: Lynda Ryall-Henke
Contact Email: Lynda.Ryall-Henke@lhsc.on.ca

Aim:
To implement a bedside swallowing screen completed by registered nurses at the bedside

Actions Taken:
After a complete literature review the group chose to implement the “Barnes Jewish Hospital Dysphagia Screen” for its validity and simplicity. Education was completed with each nurse by the clinical educator and speech language pathologist. After formal education each nurse is required to complete three screens successfully to become certified.

Summary of Results:
To date, fifteen nurses have now completed the bedside swallowing screen using the “Barnes Jewish Hospital Dysphagia Screen”. The implementation of the practice has allowed patients to be appropriately nourished in a timely fashion thereby meeting the best practice guidelines for stroke care.

Track(s):
Patient Safety

Organization Name: BIDMC
Contact Name: Michelle Sheppard
Contact Email: msheppar@bidmc.harvard.edu

Aim:
Develop a Visual Management System that would improve communication and our ability to consistently synchronize.

Actions Taken:
Switched the Admitting and Recovery areas to create line-of-sight between the 2 areas. Iterated 7 versions of a visual management board, finally implementing a strategically placed, transparent board viewable from both the procedural hall and admitting area. Reformatted previously available information using visual flags, maps, and automated patient arrival labels.

Summary of Results:
Improved communication between the admitting and procedural area and reduced phone calls within the endoscopy unit by 82%. Reduced wasted nursing time in the throughput tracking process by 74%

Track(s):
Triple Aim for Populations

Organization Name: Henry Ford Health System
Contact Name: Megan Brady
Contact Email: mbrady2@hfhs.org

Aim:
To ensure that healthcare equity is understood and practiced by Henry Ford Health System employees

Actions Taken:
Workshops, presentations, and discussions were hosted to increase awareness of disparities. A communications plan as well as “Healthcare Equity Ambassadors” supported these efforts. Cross-cultural and cross-literacy communication skills were taught, and language access services were enhanced. Race, ethnicity, and language data collection methods were revised to collect more accurate information.

Summary of Results:
Over 300 employees were trained as “Healthcare Equity Ambassadors.” Of employees in the System exposed to the Campaign, over 85% reported increased awareness of disparities and over 81% reported involvement in efforts to address them. Equity measures were embedded into quality reports, organizational strategic plans, and other System processes.

Track(s):
Improvement Capability

Organization Name: Flagler Hospital
Contact Name: William Hepler
Contact Email: bill.hepler@flaglerhospital.org

Aim:
Improve nosocomial multi-drug resistant transmission rates

Actions Taken:
Collaboration between Administration, Infection Prevention, Microbiology, Nursing, and Environmental Services to identify, control and eliminate drug resistant organisms from the hospital environment through rapid testing, prompt isolation and environmental disinfection using an active surveillance protocol and ultra-violet light disinfection.

Summary of Results:
A decrease in Vancomycin Resistant Enterococcus by 46%. A decrease in Methicillin Resistant Staphylococcus Aureus by 16%. A decrease in Clostridium difficile by 3%.

Track(s):
Patient Safety

Organization Name: Cambridge Memorial Hospital (Ontario)
Contact Name: Nisha Walibhai
Contact Email: nwalibhai@cmh.org

Aim:
Reduce ‘admit-no-bed’ time to 90 minutes for 90% of the admitted patients in ED

Actions Taken:
•Weekly senior review of ED wait time performance •Four hour analysis of potential ED admits •Utilization review of acute medical patients •ALC visual management and rounding •60 minute to bed initiative •Reorganization of physical space for medical patients to support temporary volume spikes

Summary of Results:
•ALC (Alternate Level of Care) rate reduced from over 20% to under 15% •LOS reduced by 2 days compared to same period (January to August) last year •Admit-no-bed wait time in ED reduced from 12+ hours to under 4 hours for 90% of the patients

Track(s):
Quality Cost and Value

Organization Name: North Bristol NHS Trust
Contact Name: Benjamin Plumb
Contact Email: benjamin.plumb@doctors.org.uk

Aim:
Teach QI skills and attitudes in patient safety to a generation of newly qualified doctors

Actions Taken:
Our programme of monthly meetings combined with teaching from QI experts and an organised structure of team mentors empowers trainees to undertake and complete their own QI projects and deliver improvements to their wards. These projects are seen by the Trust Board as pilot schemes, highlighting both risk and solutions.

Summary of Results:
Following our programme, 86% of trainees feel empowered to act to improve patient safety. They have all completed a small quality improvement project to effect changes on the front line and in doing so have learnt valuable skills for the future.

Track(s):
Improvement Capability

Organization Name: University of Texas MD Anderson Cancer Center
Contact Name: Sue Ferguson
Contact Email: sefergus@mdanderson.org

Aim:
To increase the Press Ganey patient satisfaction percentile rank by 10 points within a year.

Actions Taken:
A series of performance improvement initiatives were launched to improve patient satisfaction as reported by the Outpatient Satisfaction Survey using a new model incorporating employee and patient engagement, leadership commitment, and operational processes. Five process teams and improvement metrics were identified using reports and metrics from the satisfaction survey.

Summary of Results:
Through the work of the Ambulatory Patient Experience Leadership team, five interdisciplinary process teams implemented standardized rounding, reporting, and standardized several patient communication processes, resulting in an increase in the mean score for the question "information about delays" and an overall patient satisfaction 26 percentile rank increase over two years.

Track(s):
Improvement Capability