You need to be logged in to download Storyboards.
Posterboard Number:
1
Organization Name:
McAslan Consulting, PC
Contact Name:
Mary Sue McAslan
Contact Email:
marysue.mcaslan@gmail.com
Description:
Providers will be given 10 practical strategies for improving the quality of care in their practices or organizations.
Four target areas include:
1) Optimize Outcomes
a) Electronic Health Record Evolution
b) CPOE Strategies
c) Clinical Decision Support
2) Reduce Readmissions
a) Person Centered Care
b) Patient Centered Medical Homes
c) Prevent Discharge Disasters
3) Minimize Medication Errors
a) Blame Free Organization
b) Med Rec not Med Wreck
4) Promote Prevention
a) Health Literacy
b) Social Determinants of Health
Aim:
To provide healthcare practitioners and administrators with effective strategies to enhance their QI program
Actions Taken:
Getting started with quality improvement is not an impossible challenge. Start with one initiative, stick with it until it is successfully implemented, then move on to the next initiative. Keep going until your practice or institution has achieved the level of performance that you are satisfied with and proud of.
Summary of Results:
Improving the quality of care your practice or institution provides can be challenging, especially in an era of increasing demands for accountability, value and technical sophistication. Integrating these strategies into your daily medical practice or hospital can help ensure patient safety and meet quality goals.
Track(s):
Quality Cost and Value
|
|
 |
Posterboard Number:
1
Organization Name:
Alberta Health Services
Contact Name:
Vanessa MacLean
Contact Email:
Vanessa.Maclean@albertahealthservices.ca
Description:
Doctors in Mind (DIM) is a physician health education series which promotes healthy work-life balance; physical, emotional, and psychological health; and collegial interactions between physicians. This series was created and delivered for the first time to South Zone physicians in 2013-14.
Three modules were developed for the 13/14 series. Each module focused on an educational component; skill development and fostering opportunity for social interaction. The event module topics were: Nutrition and Physician Performance;
Managing Stress Effectively; and Virtual Activity Challenge.
Evaluation focused on assessing identifiable changes in health attitudes, behaviour and actions due to having participated in a DIM event.
Aim:
To achieve 25% South Zone Physician participation in the 2013/14 Doctors in Mind series.
Actions Taken:
Three modules were developed. The first two modules were delivered in 3 different communities. The third module was a virtual activity challenge.
All modules were evaluated immediately following the event. A second evaluation was offered to all physicians that had been invited to participate.
Summary of Results:
18% of all South zone physicians participated in the 2103/14 DIM series (77 of 420 physicians invited).
Quantitative and qualitative evaluation identified that participants in the series found value in attending the event.
Lessons learned focussed on series format, continuous evaluation and improved communication and planning.
Track(s):
Leadership
|
|
|
Posterboard Number:
1
Organization Name:
Sunquest Information Systems
Contact Name:
Joanne Scalise
Contact Email:
JoAnne.Scalise@gmail.com
Description:
When patient events occur, leadership takes immediate action by performing a Root Cause Analysis (RCA). When errors occur on multiple occasions and no commonalities can be identified, innovation within the traditional chronologic RCA process offers opportunities for process improvements that may otherwise remain unidentified. Utilization of the constructs of Reason’s theory as an innovative RCA approach was completed by a Northeastern hospital Emergency Department in response to a spike in patient specimen labeling errors. This innovative approach yielded opportunities for evidence based clinical practice changes as well as identification of interdisciplinary collaboration opportunities between the nursing and clinical lab.
Aim:
Innovate through application of new patient safety and error theories to current evaluative RCA practice
Actions Taken:
Collaborate with the laboratory in clearly defining the constitution of a mislabeled, incompletely labeled or unlabeled specimen.
Collaborate with the laboratory to increase the consistency of reporting of mislabeled/unlabeled specimens to 100% for reliable benchmarking metrics available to staff and leadership.
Apply Reason's theory for evidence based clinical practice changes.
Summary of Results:
Implementation of recommendations is in process, with positive response by nursing leadership and staff and improvement/reinforcement of organization safety culture. Collaboration and active interaction by all stakeholders is ongoing to improve specimen management process.
Reason's theory as well as other innovative approaches are considered in ongoing quality improvement efforts.
Track(s):
Patient Safety
|
|
|
Posterboard Number:
2
Organization Name:
The Geisinger Health System, Department of Critical Care Medicine
Contact Name:
Megan Miller-Daghir
Contact Email:
mmillerdaghir@gmail.com
Description:
Allogeneic bone marrow transplant (BMT) recipients are at risk for invasive fungal disease. BMT Protective environments (PE) were installed in new cancer tower with HEPA filtration at unit entrance and point of BMT-PE entry. Infection Control performed air sampling in new PE; two rooms yielded 20-fold more fungal isolates than all other areas (0-1 vs. 20-26 fungal colonies). An investigation was initiated.
Aim:
Identify/eliminate source[s] of fungal contamination and restore safe PE for BMT patients.
Actions Taken:
Air was sampled/cultured (Sabouraud’s agar). All filters and room closures were inspected. Hydrogen Peroxide Vapor (HPV) room decontamination was performed in both rooms/ceiling space; efficacy validated using Geobacillus stearothermophilus (spore) biological indicators. Post-HPV sampling negative. Empty soda cans/food wrappers were found; all tiles were removed and replaced by contractor.
Summary of Results:
Construction standards were violated; food was found in ceiling. Evaluation of new PEs should be considered in t he post-construction phase. Fruit/food left in a PE after HEPA filters can lead to fungal contamination/invasive fungal disease. HPV is a safe/effective way to eliminate fungal contamination in PEs.
Track(s):
Patient Safety
|
|
|
Posterboard Number:
1
Organization Name:
Rede de Hospitais São Camilo
Contact Name:
Daniela Akemi Costa
Contact Email:
daniela.akemi@saocamilo.com
Description:
The circle for quality management and safety should be understood for all staff as the main strategy of quality in our processes. In the hospital, the aim is to incorporate completely this proposal in the daily activities as opportunities of improvement in healthcare. We decided to translate these concepts in a graphical representation, connecting all different levels and areas in a common aim: Quality of Healthcare and Patient SafetY.
Aim:
To describe the construction of a graphical representation to engage staff
Actions Taken:
The spheres are the Strategic Planning, the Quality Management System and Safety, the main dimensions of quality and teamworks organized by lines of care according to epidemiological profile. The circle is proposing the motion, the dynamism of the system, which remains from four pillars: Leadership, Communication, Transdisciplinarity and Knowledge Management
Summary of Results:
The figure can be regarded as an object of institutional communication, staff training and dissemination of the culture of quality and safety, promoting synchronicity between policy, strategy and operations, and bringing meaning to everyday practices and common purpose: to increase the likelihood of better health care outcomes
Track(s):
Improvement Capability
|
|
|
Posterboard Number:
2
Organization Name:
Stanford Health Care
Contact Name:
Angela Bingham
Contact Email:
abingham@stanfordmed.org
Description:
Engagement of the multidisciplinary team is critical to effect a programmatic, patient-centered approach for improving processes related to preparing Heart Failure patients for successful self-management at home. These processes include early identification of patient cohort, risk assessment, standardized education using teach back, accurate medication reconciliation, follow up clinic appointments made prior to discharge and post discharge follow up calls. Weekly team meetings were held to plan intervention bundles, develop solutions and design an analytics dashboard, hardwired into the patient electronic medical record (EMR) and other data sources, to provide real-time process and outcome metrics.
Aim:
Collaborative project to reduce 30-day readmissions for heart failure patients by 30% within 2 years.
Actions Taken:
A Clinical Effectiveness Council formed, comprised of nurses, physicians, case managers, pharmacists and social workers, supported by Senior Leadership, Quality, Informatics- Analytics (IT), Coding and Finance formed workgroups to develop standard clinical care processes around defined interventions, design electronic tools for patient management and define metrics for sustainable outcomes.
Summary of Results:
The 30-day readmission rate for Heart Failure patients reduced from 21% to 10%. The individual core interventions pre/post results: Teachback method utilization 20% to 100%; prior to admission medication reconciliation 60% to 100%; discharge follow up clinic appointments 64% to 84%; post discharge follow up phone calls 85% to 100%.
Track(s):
Improvement Capability
|
|
|
Posterboard Number:
3
Organization Name:
YNHH
Contact Name:
Salimah Velji
Contact Email:
salimah.velji@ynhh.org
Description:
Clinical care at Smilow Cancer Hospital at Yale-New Haven is based on the multidisciplinary disease team (DT) structure across 12 clinical programs
Our goal was to develop a DT performance dashboard to identify opportunities for advancement and enhance leadership and accountability across teams
Through an iterative and collaborative process, we selected 5 strategic dimensions with 3-4 corresponding metrics each to drive improvement across: patient care, research, education, clinical business effectiveness and network integration
Aim:
Describe the clinical program performance dashboard development process, application & lessons learned
Actions Taken:
Executive Physician Sponsor met with individual DT leaders to solicit input
Metrics selected based on the following criteria: reliable, reproducible, measurable , and meaningful (R2M2)
Metrics populated by DT for a baseline and future period (inter/intra comparisons)
External national benchmarks were identified for metrics where possible
Summary of Results:
DT leaders used dashboard as a performance review tool to inform annual goals, priorities and strategy
DT leaders presented their dashboards & supplemented tool with key qualitative components: Accomplishments, Current State, Market Data, Strengths/Weaknesses/Opportunities/Threats, Goals, Initiatives to Achieve Goals & Initiative Prioritization
Metrics appropriate for inter-DT comparison presented across teams
Track(s):
Improvement Capability
|
|
|
Posterboard Number:
4
Organization Name:
Levine Childrens Hospital
Contact Name:
Cheryl D. Courtlandt
Contact Email:
cheryl.courtlandt@carolinashealthcare.org
Description:
This project is a coordinated effort between inpatient and outpatient services for pediatric asthma care, utilizing school health , home health, primary care providers and pharmacy services to decrease admissions, increase patient education and medication adhetrence and increase PCP followup
Aim:
to prevent pediatric readmission of children with asthma using a community based safety net
Actions Taken:
development of a process for transmission of HMPC to school nurse
development of home based care and education about asthma
development of school nurse contact
development of teach back protocol
assessment of followup appointments kept
Summary of Results:
A coordinated program is successful in reducing readmissions, placing more students into school based case management of thier asthma. In addition, home health services have provided support to improve patient education using Teach Back, improved medication adherence and improved primary care followup after admission
Track(s):
Improvement Capability
|
|
|
Posterboard Number:
3
Organization Name:
United Regional Health Care System
Contact Name:
Cindy Hoff
Contact Email:
choff@unitedregional.org
Description:
Fall reduction strategies expected to reduce patient falls were evaluated. The top four initiatives were introduced as the falls bundle. Once fully implementing, nurse managers began weekly audit rounds with immediate feedback of results. Nurse Managers then report weekly audit results to senior leaders. House-wide accountability and the bundle approach appear to be the key drivers. Having high risk patients wear yellow gowns allowed the entire hospital to participate in this patient safety initiative. Volunteers and physicians were included in the house wide education to monitor for patients in yellow gowns walking unassisted.
Aim:
Reduce Fall rate from 2.82 to less than 2.5 by June 2014
Actions Taken:
House wide education, signed patient safety agreements, yellow gowns for high risk patients, and weekly nurse manager accountability sessions. Staff and volunteers were educated to monitor for patients in yellow gowns walking unassisted. All high risk patients are required to have a bed/chair alarm that activates at the nurses station.
Summary of Results:
As of 9/26/2014-172 since last fall with Harm. The fall rate was reduced from the 2013 mean of 2.82 to 1.09 in August of 2014 and the overall yearly rate was reduced to 2.25. The fall rate for August is the lowest the hospital has seen in over two years.
Track(s):
Patient Safety
|
|
|
Posterboard Number:
5
Description:
Last Offices is the care given to a deceased patient which demonstrates Health Care Professionals’ respect for the dead as well as upholding health and safety and legal requirements. Bereavement Care is one of the key responsibilities for registered nurses in the hospitals. The basis of this project is to reduce the time taken in performing last offices in order to allow grieving families to pay their last respect before transporting the deceased to the mortuary.
Aim:
Decrease time taken to perform last office procedures by 50% in Ward52B in 6 months
Actions Taken:
The “In time of Need kit” house all consumables required to perform last office. A “newly designed mortuary shroud” minimized process of laying and aligning shroud multiple times to dress the deceased. Administrative forms were separated into a “Blue & Yellow” folder to differentiate between coroners and non-coroners case.
Summary of Results:
Team has achieved 68% reduction of total average process time taken to perform last office procedure. In addition, a reduction of 1 manpower was achieved which derived to a 79% reduction of overall time saved to perform the procedure.
Track(s):
Improvement Capability
|
|
|
|
OR
|
