Six Sigma Approach to Reduction of Infections. Lois Yingling, RNC, MSN, CPHQ, Black Belt Florida Hospital Orlando, Florida
|
|
- Annabel Carter
- 5 years ago
- Views:
Transcription
1 Six Sigma Approach to Reduction of Infections Lois Yingling, RNC, MSN, CPHQ, Black Belt Florida Hospital Orlando, Florida
2 Objectives At the conclusion of the presentation participants will: List the 5 steps of Six Sigma Identify components of the IHI central line bundle Appreciate the value of a systematic approach to process improvement
3 Overview Who is Florida Hospital Bloodstream infections Five steps of Six Sigma Define Measure Analyze Improve Control Lessons learned with CDT
4 Who is Florida Hospital? Founded in 1908 by Adventist Church Oldest & largest healthcare system in Central Florida Seven campuses in 3 counties Licensed for over 1800 beds Third largest employer in Central Florida Largest Medicare population in the nation Recognized as one of America s Best Hospitals in U.S. News & World Report for the seventh year in a row HealthGrades 2005 Award for Excellence in Patient Safety
5 DMAICMAIC Define
6 Why Bloodstream Infection (BSI) Published mortality rates as high as 35% Baseline CVC related BSI: 13% Additional therapy costs $56,000 Baseline CVC related BSI: $16,699 variable cost Increased length of stay Baseline CVC related BSI: 20.6 additional days per case
7 National Interest Institute for Healthcare Quality (IHI) Central line bundle Hand hygiene Maximal barrier precautions Chlorhexadine skin antisepsis Appropriate care of site and line system No routine replacement Center for Disease Control (CDC) Guidelines
8 DMAIC Measure
9 In Scope: Scope Inpatients system-wide >17 y/o Positive blood culture within 48 hours of admission (2 weeks re- admission) Confirmed based on CDC definition CVC Out of Scope PICC lines Tunneled, port, dialysis, peripherals
10 Project Description/ Problem Statement Based on 2003 & annualized 2004 data: 43% of BSIs were secondary to CVCs LOS is increased by 20.6 days per case Variable treatment cost is increased by $16,699 per case Goal: Decrease the number of CVC related cases by 10%, a decrease of 16 cases per year
11 SIPOC High Level Process Map Supplier Input Process Output Customer Start = line Insertion Physician Referral Select device No BSI Patient Line Select site BSI Family Protective Garb Don full barrier garb Tray Prep site Insert line Care for line & dressing End = line removal
12 Baseline Process in control, no special cause variation
13 Gauge Repeatability Patient ICP Initial Surveillance Determination Surveillance ICP Second Surveillance Determination Surveillance result Agree Disagree result BSI Surveillance Hospital Acquired Hospital Acquired BSI Surveillance Hospital Acquired Hospital Acquired BSI Surveillance Hospital Acquired Hospital Acquired BSI Surveillance Hospital Acquired Hospital Acquired UTI Surveillance Hospital Acquired Hospital Acquired UTI Surveillance Hospital Acquired Hospital Acquired UTI Surveillance Hospital Acquired Hospital Acquired CDT Surveillance Hospital Acquired Hospital Acquired CDT Surveillance Hospital Acquired Hospital Acquired CDT Surveillance Hospital Acquired Hospital Acquired Total % One person repeatedly measures same unit
14 Gauge Reproducibility ICP #1 ICP#2 Agree Disagree Patient Surveillance result Surveillance result BSI Surveillance Hospital Acquired Hospital Acquired BSI Surveillance Hospital Acquired Hospital Acquired BSI Surveillance Hospital Acquired Hospital Acquired BSI Surveillance Hospital Acquired Hospital Acquired UTI Surveillance Hospital Acquired Hospital Acquired UTI Surveillance Hospital Acquired Hospital Acquired UTI Surveillance Hospital Acquired Not Hospital Acquired CDT Surveillance Hospital Acquired Hospital Acquired CDT Surveillance Hospital Acquired Hospital Acquired CDT Surveillance Hospital Acquired Hospital Acquired Total % Two or more persons measure the same unit
15 DMAIC Analyze
16 Process Capability Y1 All BSI Overall Z.USL Sigma 0
17 Vital Xs CVC related blood stream infections cause & effect fishbone Patient/Visitor Equipment Technique Hand hygiene Handling catheter Handling drsg Visitors Patient Physician Staff Antimicrobial catheter Non-antimicrobial catheter Cost Stabilizer Contamination Hub care Dressing A septic techniue Line maintenance Hand hygiene Hand hygiene Sterile barrier Sk ill level Prep Contamination BSI PICC Candidate Femoral Subclavien Jugular Education Catheter Care Site
18 DMAIC Improve
19 Interventions & Results Nail P&P Chloraprep Staff BSI Education Began conversion to antimicrobial catheters in custom trays with sterile garb in all trays except Anesthesia Trays Hand Hygiene Campaign
20 Statistical Significance Two-Sample T-Test and CI: Historical VS New Mean Two-sample T for Rate C7 N Mean StDev SE Mean (Jan November 2003) (Nov January 2005) Difference = mu (1) - mu (2) Estimate for difference: % CI for difference: ( , ) T-Test of difference = 0 (vs not =): T-Value = 5.21 P-Value = DF = 19 Difference between historical & new mean is statistically significant
21 Error Proofing Trays Custom Trays: Anesthesia Trays - no sterile garb ED & Unit Trays sterile garb Issue: Anesthesia trays without sterile garb distributed to units Error Proof: All custom trays include sterile garb and antimicrobial catheter
22 DMAIC Control
23 Reliable Measurements What to Measure Total Blood Stream Infections Clarify Data Collection Goals Type of Measure Y=BSI Rate Type of Data Continuous Data Operational Definition Procedure & What How X 1 X Data Form What Where When Positive Blood culture after 48 hours od admission or readmission within 7 days for S&S if BSI Query Medmined for positive blood cultures Develop Operational Definitions and Procedures Other Conditions to Record Line Type: CVC Swan Ganz, PICC, tunneled Collecting and Recording Infection Control Survelance Criteria for Center for disease Control Definition BSI Sampling Plan How Many Systemwide Monthly!00% X=number of infections secondary to CVC Discrete data Same as above Same as above Extarpolate CVC lines Confirmed BSI secondary to CVC line Review records for accuracy Systemwide Monthly!00% Gage R&R for all new emplyees after 90 days & for all staff annually. Gage R&R may be done more frequently if indicated. BSI Rate is based on CDC definition. CVC related BSI extrapolated from total BSI cases.
24 Current Status I Chart of CVC BSI Rate Historical VS New Mean Data Source: AICE Per 1000 Patient Days UCL=0.733 _ X= LCL=0.033 Marc h June Septe mbe r De cember Marc h Jun e Septe mber De cembe r Ma rc h Jun e January 2003 through July 2005 Process is in Control
25 Target: 5 or Less/Month
26 Process Capability Process Capability of Rate P rocess D ata LS L * Target * U S L S am ple M ean Sample N 18 S td ev (Within) S td ev (O v erall) USL Within Overall P ote ntial (W ithin) C apability Z.Bench 0.32 Z.LS L * Z.U S L 0.32 Cpk 0.11 CCpk 0.11 O v erall C apability Z.Bench 0.30 Z.LS L * Z.U S L 0.30 Ppk 0.10 Cpm * O bserv ed P erform ance PPM < LSL * P P M > U S L P P M Total Exp. Within Performance PPM < LSL * P P M > U S L P P M Total E xp. O v erall P erform ance PPM < LSL * P P M > U S L P P M Total Y1 All BSI overall Z.USL 0.30 current Sigma 1.8
27 Owner Accountability What Who When Data collection Process Confirmed with IC Director & Manager Director Monthly beginning June 2005 Monthly report of CVC BSI Cases & LOS by Campus to Esmond Chan Variable cost/capacity adjustment Director Financial Analyst Monthly beginning June 2005 January 2005 & monthly
28 Results Capacity YTD April Actual 296 Days Target 110 Days Variance 186 Days Dollar Savings YTD April Actual $207,196 Target $77,233 Variance $129,963
29 CDT: Lessons Learned
30 Scope: Containment In Scope: Inpatients system-wide >17 y/o Diarrhea with confirmed assay diagnosis of CDT Out of Scope Outpatients Inpatients without diarrhea & confirmed assay diagnosis of CDT
31 Scope: Prevention In Scope: Inpatients system-wide, except Campus 3, >17 y/o with a history of a surgical procedure on the SIP list Diarrhea with confirmed assay diagnosis CDT Out of Scope All patients admitted to Campus 3 All medical patients and all surgical patients not on SIP list
32 CDT Baseline Out of Control I Chart of CDT Rate Individual Value UCL=4.530 _ X= LCL= March June 1 S eptem ber December March June September Decem ber Marc h Month Baseline 2003 through June 2004 June
33 CDT Rate I Chart of CDT Rate Pre-Assay VS Post Assay Data Source: AICE Per 1000 Patient Days UCL=5.117 _ X=4.195 LCL= March June S eptem ber Dec ember March January 2003 through May 2004 June Septem ber Decem ber Marc h June June 2004 through June % Assay Testing increased Case Finding
34 Containment Bleach April 2005 Terminal Cleans with bleach for rooms of CDT patients May 2005 Error Proofing Terminal Cleans for all rooms July Pilot Campus 6 New non-bleach product Kills spores No damage to furniture
35 CDT Rate
36 CDT Cases/Month Terminal bleach clean CDT rooms Terminal bleach clean all Rooms June 2005: Target 152 or less/month
37 Prevention Right Antibiotic Right time Within one hour of incision Right duration Discontinue within 24 hours for prophylaxis Document if treating infection
38 Business Case Improved clinical quality (absence of infection) Capacity opportunity of 1639 days Financial opportunity of $1,298,484
39 Summary Six Sigma: Well defined methodology Systematic approach Robust Data driven Directional Statistical application for other initiatives
40 Alice came to a fork in the road. Which road do I take? she asked. Where do you want to go? responded the Cheshire cat? I don t know. Alice answered. Then said the cat, it doesn t matter. From Alice in Wonderland by Lewis Carroll
Using Care Bundles to Reduce Catheter Associated Blood Stream Infections in the NICU. Dr David Ng Paediatric Medical Officer Sarawak General Hospital
Using Care Bundles to Reduce Catheter Associated Blood Stream Infections in the NICU Dr David Ng Paediatric Medical Officer Sarawak General Hospital Outline of Presentation Introduction Definition of CABSI
More information2018 BSI QIA. Kick off Part 1. Annabelle Perez Quality Improvement Director
2018 BSI QIA Kick off Part 1 Annabelle Perez Quality Improvement Director Outline 2018 BSI QIA Overview What does it really mean to follow the CDC Core Interventions Next Steps 2018 BSI QIA Overview BSI
More informationConsumers Union/Safe Patient Project Page 1 of 7
Improving Hospital and Patient Safety: An overview of recently passed legislation and requirements towards improving the safety of California s hospital patients June 2009 Background Since 2006 several
More informationCLABSI Prevention Hardwiring Improvement
CLABSI Prevention Hardwiring Improvement Brian Koll MD, FACP, FIDSA Executive Director, Infection Prevention Mount Sinai Health System Professor of Medicine, Icahn School of Medicine September 29, 2014
More informationAPPLICATION FORM. Sepsis: A Health System s Journey Toward Optimal Patient Care & Outcomes. Director of Quality
APPLICATION FORM Title of Entry: Sepsis: A Health System s Journey Toward Optimal Patient Care & Outcomes Division: Large Organizations Award: Excellence in Care Entrant s Name and Title: Maurita K. Marhalik,
More informationWorth a Thousand Words: Telling a Story with Data
A5/B5 Worth a Thousand Words: Telling a Story with Data Ari Robicsek, MD Chief Medical Analytics Officer Providence St. Joseph Health Session Objectives Consider the challenges of representing patient
More informationDescribe the impact of CLABSI on patients and their families. Discuss three methods of reducing CLABSIs
Describe the impact of CLABSI on patients and their families. Discuss three methods of reducing CLABSIs Explore the essential elements of maintaining decreased CLABSIs 1 2001-43,000 CLABSIs In ICUs 2009-18,000
More informationHAI Prevention. Beyond the Bundle. March 18, 2016
HAI Prevention Beyond the Bundle March 18, 2016 Krystyna Strozewski Director of Quality Lake Health System Karen Mrazik Infection Preventionist Tripoint Medical Center Elizabeth Reed Infection Preventionist
More informationCentral Line Bundle Education. National Patient Safety Goal Preventing Central Line Infections 2010
Central Line Bundle Education National Patient Safety Goal 07.04.01 Preventing Central Line Infections 2010 Central Line Associated Bloodstream Infections CAN and DO kill our patients. THE GOOD NEWS They
More informationReducing Surgical Site Infections in Colon Surgery Patients
Reducing Surgical Site Infections in Colon Surgery Patients Mercy Health St. Elizabeth Boardman Hospital A Catholic healthcare ministry serving Ohio and Kentucky Mercy Health St. Elizabeth Boardman Hospital
More informationReducing Infections and Improving Engagement St. Luke's Nephrology Associates. Contact Information: Robert Gayner, M.D., FASN
BEST PRACTICES Vascular Access and CLABSI Reduction Reducing Infections and Improving Engagement St. Luke's Nephrology Associates Contact Information: Robert Gayner, M.D., FASN St. Luke's Nephrology Associates
More informationImplementation Guide for Central Line Associated Blood Stream Infection
Implementation Guide for Central Line Associated Blood Stream Infection March 27, 2013 Contents 1. Introduction... 3 2. Central Line Associated Blood Stream Infection Prevention Evidence-Based Practices...
More informationWHY IMPLEMENT CENTRAL LINE INSERTION BUNDLES
WHY IMPLEMENT CENTRAL LINE INSERTION BUNDLES WHY IMPLEMENT A CENTRAL LINE BUNDLE? Hospital-acquired infections (HAIs) are the fourth largest killer in America. The death toll from HAIs is estimated at
More informationHCA Infection Control Surveillance Survey
HCA Infection Control Surveillance Survey HCA is very interested in reducing nosocomial infections in its hospitals. A key to reducing infections is for each hospital to have a robust infection control
More informationBeth Ann Ayala, Jim Lewis, and Tom Patterson DATE. Educating for Quality Improvement & Patient Safety
Beth Ann Ayala, Jim Lewis, and Tom Patterson DATE Educating for Quality Improvement & Patient Safety 1 The Team CSE participants Tom Patterson,MD - Professor of Medicine Division Head and Chief, Infectious
More informationHealthcare Acquired Infections
Healthcare Acquired Infections Emerging Trends in Hospital Administration 9 th & 10 th May 2014 Prof. Hannah Priya HICC In charge What is healthcare acquired infection? An infection occurring in a patient
More informationTranslating Evidence to Safer Care
Translating Evidence to Safer Care Patient Safety Research Introductory Course Session 7 Albert W Wu, MD, MPH Former Senior Adviser, WHO Professor of Health Policy & Management, Johns Hopkins Bloomberg
More informationFrequently Asked Questions. Last updated: 17/11/10
Frequently Asked Questions Last updated: 17/11/10 Completion of the Surveillance Form: For which patients in ICU should I complete a surveillance form? Fill out a form for all patients in your ICU that
More informationDecreasing Nosocomial C. diff
Decreasing Nosocomial C. diff Our journey to decreasing nosocomial C. diff Jennifer Conti BSN, RN, CIC Nicole Rabic MSN, RN, CIC 4.21.2016 Nosocomial C. diff Use of the CDC standardized definition Review
More informationPatricia Church, MSN, RN, PCNS-BC, CPON Bernice Mowery, PhD, PNP, RN
Beyond the Bundle: Strategies to Prevent Catheter Related Blood Stream Infections in a Pediatric Oncology In- Patient Unit Patricia Church, MSN, RN, PCNS-BC, CPON Bernice Mowery, PhD, PNP, RN Objectives
More informationUNIVERSITY OF ILLINOIS HOSPITAL & HEALTH SCIENCES SYSTEM HOSPITAL DASHBOARD
September 8, 20 UNIVERSITY OF ILLINOIS HOSPITAL & HEALTH SCIENCES SYSTEM HOSPITAL DASHBOARD UI Health Metrics FY Q4 Actual FY Q4 Target FY Q4 Actual 4th Quarter % change FY vs FY Average Daily Census (ADC)
More informationProvincial Surveillance
Provincial Surveillance Provincial Surveillance 2011/12 Launched first provincial surveillance protocols Establishment of provincial data entry & start of formal surveillance reports Partnership with AB
More informationSurgical Site Infection Prevention: Guidelines, Recommendations and Best Practice
Surgical Site Infection Prevention: Guidelines, Recommendations and Best Practice Linda Goss BS, MSN, APN-BC, CIC, COHN-S Director, Infection Prevention and Control and Vascular Access Specialist Team
More informationKey prevention strategies for MRSA bacteraemia: a case study. Dr. Michael A. Borg Director of Infection Prevention & Control Mater Dei Hospital Malta
Key prevention strategies for MRSA bacteraemia: a case study Dr. Michael A. Borg Director of Infection Prevention & Control Mater Dei Hospital Malta 1 Mortality following Staphylococcus aureus bacteraemia
More informationInfection Prevention & Control Orientation for Housestaff Welcome to Shands at UF!
Infection Prevention & Control Orientation for Housestaff 2011 Welcome to Shands at UF! Hot Topics: Prevention Initiatives National Patient Safety Goal 07: Prevent Healthcare Associated Infections Prevent
More informationOutline 1. Infection Prevention Program Bloodborne Pathogens/Exposure Prevention & Management Standard Precautions 2. Hand Hygiene 3. Isolation Precau
Erlanger Infection Prevention Resident and df Fellow Orientation June 2011 1 Outline 1. Infection Prevention Program Bloodborne Pathogens/Exposure Prevention & Management Standard Precautions 2. Hand Hygiene
More informationAn Educational Intervention to Increase CLABSI Bundle Compliance in the ICU. A thesis presented by. Shelby L. Holden
Shelby Holden 1 An Educational Intervention to Increase CLABSI Bundle Compliance in the ICU A thesis presented by Shelby L. Holden Presented to the College of Education and Health Professions in partial
More informationUNIVERSITY OF ILLINOIS HOSPITAL & HEALTH SCIENCES SYSTEM HOSPITAL DASHBOARD
UNIVERSITY OF ILLINOIS HOSPITAL & HEALTH SCIENCES SYSTEM HOSPITAL DASHBOARD January 19, 2017 UI Health Metrics FY17 Q1 Actual FY17 Q1 Target FY Q1 Actual Ist Quarter % change FY17 vs FY Discharges 4,836
More informationUI Health Hospital Dashboard September 7, 2017
UI Health Hospital Dashboard September 20 September 7, 20 UI Health Metrics FY Q4 Actual FY Q4 Target FY Q4 Actual 4th Quarter % change FY vs FY Discharges 4,558 4,680 4,720 Combined Observation Cases
More information2014 Partnership in Prevention Award. November 21, :00-1:00PM EST. Introduction
2014 Partnership in Prevention Award November 21, 2014 12:00-1:00PM EST Introduction Don Wright, MD, MPH Deputy Assistant Secretary for Health (Disease Prevention and Health Promotion) U.S. Department
More informationHardwiring Processes to Improve Patient Outcomes
Hardwiring Processes to Improve Patient Outcomes Barbara Adcock Mohr, Administrative Director, Rehabilitation Services Mark Prochazka, Assistant Director, Rehabilitation Services UNC Hospitals FIM, UDSMR,
More informationOur falls rate is consistently below national
Our falls rate is consistently below national benchmarks, but with the lessons learned from Falls Huddle rounding, we anticipate further decreases in the overall fall rate and repeater fall rate. Monica
More informationESRD Network 5: Prevention Process Measure Training Christi Lines, MPH
ESRD Network 5: Prevention Process Measure Training Christi Lines, MPH January 26, 2016 Outline Overview of NHSN surveillance Brief review of Dialysis Event surveillance The value of auditing prevention
More informationSuccessfully Using Six Sigma. (6σ) to Improve Nursing Quality. Indictors. Objectives. 1. Describe how Six Sigma can be used to
Successfully Using Six Sigma (6σ) to Improve Nursing Quality Indictors Joann Hatton, RN MS, 6σ Black Belt Director of Nursing Professional Practice Heritage Valley Health System Beaver, PA Objectives 1.
More informationIntegrating Quality Into Your CDI Program: The Case for All-Payer Review
7th Annual Association for Clinical Documentation Improvement Specialists Conference Integrating Quality Into Your CDI Program: The Case for All-Payer Review Katy Good, RN, BSN, CCDS, CCS CDI Program Coordinator
More informationTHE JOURNEY TO CLINICAL INDICATION: TIME TO MOVE THE NEEDLE
THE JOURNEY TO CLINICAL INDICATION: TIME TO MOVE THE NEEDLE Michelle DeVries, BS, MPH, CIC Senior Infection Preventionist Methodist Hospitals Gary, IN Michelle DeVries is a paid consultant of Ethicon US,
More informationA System-Based Approach to Colorectal Surgery SSI Reduction: Interventions Across the Episode of Care
A System-Based Approach to Colorectal Surgery SSI Reduction: Interventions Across the Episode of Care Robert R. Cima, MD, MA Minnesota SSI Reduction Effort December 2013 2011 MFMER slide-1 Attestation
More informationCentral Line Bundle Brochure - Achieving Excellence in Patient Care Brochure Highlights and Contact Information
Central Line Bundle Brochure - Achieving Excellence in Patient Care Brochure Highlights and Contact Information Goal: Preventing central line infections Focus: Central Line Bundle Hand Hygiene - Epi-Clenz
More informationMeeting the NEW RCN Standards for Infusion Therapy in practice
Meeting the NEW RCN Standards for Infusion Therapy in practice sumanshrestha@nhs.net Suman Shrestha MSc BSc RN Advanced Nurse Practitioner Intensive Care Frimley Park Hospital suman_sr FRIMLEY PARK HOSPITAL
More information2017 Nicolas E. Davies Enterprise Award of Excellence
2017 Nicolas E. Davies Enterprise Award of Excellence Agenda Memorial Hermann Health System Overview Journey to High Reliability Case study review CLABSI Prevention 2 Memorial Hermann Health System Woodlands
More informationPracticing Six Sigma for Medical Group Practice Success
Practicing Six Sigma for Medical Group Practice Success Cardiovascular Consultants Pasteplus Improvement Team Author: Mark Stewart Tertiary care regional hospital 21 county service area; 285,000 people
More informationInfection Control: Reducing Hospital Acquired Central Line Bloodstream Infections
The University of San Francisco USF Scholarship: a digital repository @ Gleeson Library Geschke Center Master's Projects and Capstones Theses, Dissertations, Capstones and Projects Spring 5-19-2017 Infection
More informationHospital-Acquired Infections Prevention is in Your Hands. Rachel L. Stricof
Hospital-Acquired Infections Prevention is in Your Hands Rachel L. Stricof rstricof@gmail.com Morbidity 1.7 Million infections per year (estimate 2002) Mortality 99,000 deaths per year (estimate 2002)
More informationBundle Me Up! Using Central Line Bundles to Decrease Infection
Bundle Me Up! Using Central Line Bundles to Decrease Infection Organization Name: Peninsula Regional : Acute Care Hospital Medical Center Contact Person: Regina Kundell Title: Dir, Women s and Children
More informationNOTE: New Hampshire rules, to
NOTE: New Hampshire rules, 309.01 to 309.08 Email Request: Selected Items in Table of Contents: (8) Time Of Request: Sunday, August 07, 2011 18:11:07 EST Send To: MEGADEAL, ACADEMIC UNIVERSE UNIVERSITY
More informationRole of the C-Suite in High Reliability Antimicrobial Stewardship
Role of the C-Suite in High Reliability Antimicrobial Stewardship 1 st Annual Texas Medical Center Antimicrobial Resistance and Stewardship Conference January 19, 2018 M. Michael Shabot, MD, FACS, FCCM,
More informationBuilding a Culture That Lasts
Building a Culture That Lasts Establishing a Leadership Legacy Quality Texas Foundation June 28, 2016 M. Michael Shabot, MD, FACS, FCCM, FACMI Executive Vice President System Chief Clinical Officer V2
More informationJoint Commission NPSG 7: 2011 Update and 2012 Preview
Joint Commission NPSG 7: 2011 Update and 2012 Preview Pharmacy OneSource Webinar June 1, 2011 Louise M. Kuhny, RN, MPH, MBA, CIC The Joint Commission Objectives Upon completion of this program, participants
More informationPatient Safety. If you have any questions, contact: Sheila Henssler Performance Improvement/Patient Safety Coordinator Updated:
Patient Safety If you have any questions, contact: Sheila Henssler Performance Improvement/Patient Safety Coordinator 615-7018 Updated: 2013-05-03 Learning Objectives In this presentation, you will learn:
More informationQUALIS HEALTH HONORS WASHINGTON HEALTHCARE PROVIDERS
LEADERSHIP IN IMPROVING HEALTHCARE Harborview Medical Center Code Sepsis: Improving Survival in Sepsis with Early Identification and Activation of a Critical Care Team Sepsis, one of the highest causes
More informationNational Programme to Prevent Central-Line Associated Bacteraemia. Project Charter October 2011 to April 2013
National Programme to Prevent Central-Line Associated Bacteraemia Project Charter October 2011 to April 2013 1. Overview Central-Line Associated Bacteraemia (CLAB) prevention is one of the most important
More informationOrganization: Frederick Memorial Hospital. Solution Title: We Found the Missing Piece to Our CLABSI Puzzle
Organization: Frederick Memorial Hospital Solution Title: We Found the Missing Piece to Our CLABSI Puzzle Program/Project Description: Hospitalized patients are at risk every day for contracting infections.
More informationEstablishing a Culture of Quality and Safety and the Journey to High Reliability
Establishing a Culture of Quality and Safety and the Journey to High Reliability Becker s Hospital Review May 9, 2013 Charles D. Stokes System Chief Operating Officer M. Michael Shabot, M.D. System Chief
More informationAPIC NHSN Webinar. Kathy Allen-Bridson, Janet Brooks, Cindy Gross, Denise Leaptrot, Susan Morabit, & Eileen Scalise Subject Matter Experts
APIC NHSN Webinar Kathy Allen-Bridson, Janet Brooks, Cindy Gross, Denise Leaptrot, Susan Morabit, & Eileen Scalise Subject Matter Experts April 27, 2015 National Center for Emerging and Zoonotic Infectious
More informationSARASOTA MEMORIAL HOSPITAL NURSING PROCEDURE
SARASOTA MEMORIAL HOSPITAL NURSING PROCEDURE TITLE: ISSUED FOR: HEMODIALYSIS TEMPORARY CATHETER (INSERTION, DRESSING CHANGE, REMOVAL, MEDICATION AND BLOOD DRAWS, DISCONTINUATION OF MEDS AND IV FLUIDS)
More informationReal Time CLABSI Case Reviews at HCMC. Mary Ellen Bennett Steph Laskowski
Real Time CLABSI Case Reviews at HCMC Mary Ellen Bennett Steph Laskowski RCA vs Real Time Case Review Similar: event review with stakeholders, no blame, gives ideas on what could be done better, focus
More informationLean Six Sigma in Healthcare. 4 Simple BFO s s that Change Everything
Lean Six Sigma in Healthcare 4 Simple BFO s s that Change Everything Presented By: Joseph Duhig Senior Vice President Juran Institute, Inc. February 23, 2008 BFO s = Blinding Flashes of the Obvious 8005
More informationNational External Ventricular Drain (EVD) Program and Database. David Darrow, MD MPH Coridon Quinn, MD
National External Ventricular Drain (EVD) Program and Database David Darrow, MD MPH Coridon Quinn, MD Department of Neurosurgery Dr. Matthew Hunt Dr. Stephen Haines Acknowledgements Disclosures Dr. Darrow:
More informationCMS and NHSN: What s New for Infection Preventionists in 2013
CMS and NHSN: What s New for Infection Preventionists in 2013 Joan Hebden RN, MS, CIC Clinical Program Manager Sentri7 Wolters Kluwer Health - Clinical Solutions Objectives Define the current status of
More informationSARASOTA MEMORIAL HOSPITAL STANDARDS OF CARE STANDARDS OF PRACTICE DEPARTMENT OF IV THERAPY (IV THERAPISTS)
UNIT: SARASOTA MEMORIAL HOSPITAL STANDARDS OF CARE STANDARDS OF PRACTICE DEPARTMENT OF IV THERAPY (IV THERAPISTS) STANDARD #: EFFECTIVE DATE: REVISED DATE: STANDARD TYPE: 04/91 5/05, 3/08 DEPARTMENTAL
More informationHospital Acquired Conditions. Tracy Blair MSN, RN
Hospital Acquired Conditions Tracy Blair MSN, RN A hospitalacquired infection (HAI), also known as a nosocomial infection, is an infection that is acquired in a hospital or other health care facility Hospital
More informationHOSPITAL ACQUIRED COMPLICATIONS. Shruti Scott, DO, MPH Department of Medicine UCI Hospitalist Program
HOSPITAL ACQUIRED COMPLICATIONS Shruti Scott, DO, MPH Department of Medicine UCI Hospitalist Program HOSPITAL ACQUIRED COMPLICATIONS (HACS) A medical condition or complication that a patient develops during
More informationThe Blueprint for Quality is the Framework for Clinical Strategy at UPHS
Assessing the Financial Impact of a Unit Based Clinical Leadership Model at a University Hospital: A Case Study of Reductions in Catheter- Associated Bloodstream Infections (BSI) J Doshi, PhD; P Li, PhD,
More informationHow to prioritize resources and strategies on control of MDRO. Dr Ling Moi Lin Director of Infection Control Singapore General Hospital
How to prioritize resources and strategies on control of MDRO Dr Ling Moi Lin Director of Infection Control Singapore General Hospital Preliminary questions What is a MDRO? Do I have a MDRO problem? Which
More informationThe Nurse s Role in Preventing CLABSI
The Nurse s Role in Preventing CLABSI This course has been awarded one (1.0) contact hour. This course expires on February 28, 2020 Copyright 2017 by RN.com. All Rights Reserved. Reproduction and distribution
More informationC. difficile Infection and C. difficile Lab ID Reporting in NHSN
C. difficile Infection and C. difficile Lab ID Reporting in NHSN MARY ANDRUS, BA, RN, CIC Infection Preventionist Consultant Learning Objectives Review the structure and of the MDRO/CDAD Module within
More informationHRET HIIN MDRO Taking MDRO Prevention to the Next Level!
HRET HIIN MDRO Taking MDRO Prevention to the Next Level! October 17, 2017 12:30 p.m. 1:30 p.m. CT 1 Kristin Preihs Senior Program Manager, HRET WELCOME AND INTRODUCTIONS 2 Webinar Platform Quick Reference
More informationCMS TRANSPLANT PROGRAM QUALITY WEBINAR SERIES. James Ballard, MBA, CPHQ, CPPS, HACP Eileen Willey, MSN, BSN, RN, CPHQ, HACP
CMS TRANSPLANT PROGRAM QUALITY WEBINAR SERIES Comprehensive Program and 5 Key Aspects James Ballard, MBA, CPHQ, CPPS, HACP Eileen Willey, MSN, BSN, RN, CPHQ, HACP QAPI Specialist/ Quality Surveyor Educators
More informationTools & Resources for QI Success
Tools & Resources for QI Success Pediatric Hospital Medicine National Conference Kiran Kulkarni, MD Cynthia Castiglioni, MD, MS (HQPS) Sangeeta Schroeder, MD, MS (HQPS) Anu Subramony, MD MBA July 22, 2017
More informationLessons From Infection Prevention Research in Emergency Medicine: Methods and Outcomes
Lessons From Infection Prevention Research in Emergency Medicine: Methods and Outcomes Patricia W. Stone, PhD, RN FAAN Centennial Professor in Health Policy Director PhD Program and Director Center for
More informationCenters for Disease Control and Prevention (CDC) Patient Hand Hygiene Audit Information and Instructions
Centers for Disease Control and Prevention (CDC) Patient Hand Hygiene Audit Information and Instructions You have agreed to help the Network by doing a very important Hand Hygiene Audit. We thank you for
More informationColorectal SSI Reduction and Collaboration with the Center for Transforming Healthcare
Colorectal SSI Reduction and Collaboration with the Center for Transforming Healthcare Lessons I Learned Robert R. Cima, MD 2012 ACS NSQIP National Conference July 22-24, 2012 2011 MFMER slide-1 Mayo Clinic,
More informationMaking Dialysis Safer for Patients Coalition
National Center for Emerging and Zoonotic Infectious Diseases Making Dialysis Safer for Patients Coalition Christi Lines, MPH NANT Symposium February 2017 Outline Introduction to the Coalition Coalition
More informationHealthcare-Associated Infections (HAI) Quality Improvement Activity February Webinar
Healthcare-Associated Infections (HAI) Quality Improvement Activity 2017 February Webinar AIM : Better Care for the Individual through Patient and Family Centered Care Patient Safety: Healthcare-associated
More informationUNC2 Practice Test. Select the correct response and jot down your rationale for choosing the answer.
UNC2 Practice Test Select the correct response and jot down your rationale for choosing the answer. 1. An MSN needs to assign a staff member to assist a medical director in the development of a quality
More informationAMERICAN COLLEGE OF SURGEONS Inspiring Quality: Highest Standards, Better Outcomes
AMERICAN COLLEGE OF SURGEONS Inspiring Quality: Highest Standards, Better Outcomes SSI Measure Harmonization ACS NSQIP and CDC NHSN Bruce Lee Hall, MD, PhD, MBA, FACS 2012 ACS NSQIP National Conference
More informationInfluence of Patient Flow on Quality Care
Influence of Patient Flow on Quality Care Patients Waiting on Trolleys for an Inpatient Bed Patients who are Medically Fit to be discharged and cared for at Home with Support or in a Nursing Home or District
More information"Risky Business", Staff -Patient Safety Newsletter
"Risky Business", Staff -Patient Safety Newsletter St. Joseph Medical Center Program/Project Description. When reviewing medication incident report data, we observed that similar errors were occurring
More informationReducing Central Line Associated Blood Stream Infection (C.L.A.B.S.I.) System and Patient Tracer
Reducing C.L.A.B.S.I.: SYSTEM Tracer Begin with Large Group General Questions: 1. Describe your surgical and then medical process related to the prevention of C.L.A.B.S.I. 2. Create questions that come
More informationPrairie North Regional Health Authority: Hospital-acquired infections
Prairie North Regional Health Authority: Hospital-acquired infections Main points... 308 Introduction... 309 Background the risk of hospital-acquired infections... 309 Audit objective, scope, criteria,
More informationUniversity of Illinois Hospital and Clinics Dashboard May 2018
May 17, 2018 University of Illinois Hospital and Clinics Dashboard May 2018 Combined Discharges and Observation Cases for the nine months ending March 2018 are 1.6% below budget and 4.9% lower than last
More informationOptimizing Care for Complex Patients with COPD
Optimizing Care for Complex Patients with COPD Janice Gasaway, RN, MN, Director Quality & Safety Elvin Perkins, MBA, Chronic Disease Project Manager 1 Cone Health System: Who We Are Regional Health System
More informationDelivering Standardized Evidencebased Practice to Improve Quality and Contain Costs
Delivering Standardized Evidencebased Practice to Improve Quality and Contain Costs Robert E Murphy, MD Chief Medical Informatics Officer Memorial Hermann Healthcare System HIMSS Webinar November 21, 2013
More informationPractical Skills Building Session: Control Charts Worksheets
2018 frican Forum on Quality and Safety in Healthcare Practical Skills Building Session: Control Charts Worksheets Faculty Robert Lloyd, PhD, Vice President Institute for Healthcare Improvement 20 February
More informationNurse Driven Foley Removal Protocol. Cathy Moore, MSN, ACNS-BC, CCRN 2009
Nurse Driven Foley Removal Protocol Cathy Moore, MSN, ACNS-BC, CCRN 2009 Abstract Text Nosocomial urinary tract infections (UTI) are common and costly occurrences for hospitalized patients. Patients may
More informationFee: The fee for the 12-month renewal is $10,000.
CHILDHOOD CANCER AND BLOOD DISORDERS NETWORK 2017 RENEWAL TOOLS HOW TO Renew To renew, simply submit a completed Childhood Cancer & Blood Disorders Network Renewal Form to Gena Paulk via email at gena.paulk@childrenshospitals.org.
More informationQuality Improvement: Engaging the Team
Quality Improvement: Engaging the Team Leadership Council for Clinical Quality, Safety and Service Goals Quality & Safety Reduce Potential Preventable Quality & Safety Events Achieve top decile status
More informationIdentify patients with Active Surveillance Cultures (ASC)
MRSA CHANGE STRATEGIES The following tables include change strategies proven to be effective in healthcare settings. Implementing these changes through current or new processes may result in reducing healthcare
More informationA Pilot Study in Performance Improvement CME: Using an Electronic Health Record for Guided Self Assessment and Learning
A Pilot Study in Performance Improvement CME: Using an Electronic Health Record for Guided Self Assessment and Learning Joseph L. Seltzer, MD Jeanne G. Cole, MS Nothing to disclose Timely Administration
More informationBaptist Health System Jacksonville, FL
Baptist Health System Jacksonville, FL Baptist Health System Community Leader in Healthcare Five (5) Hospital System Serving greater Jacksonville area and SE Georgia Children s Hospital Primary Care Facilities
More informationIs It Really Clean? Quality Checks For Environmental Cleaning
Is It Really Clean? Quality Checks For Environmental Cleaning Presentation to: Quality Alliant QIO conference call Presented by: Bonnie Norrick, MT(ASCP) CIC, CPHQ Lead Infection Preventionist DPH Date:
More informationAccreditation Program: Long Term Care
ccreditation Program: Long Term are National Patient Safety Goals indicates scoring category ; indicates scoring category ; indicates situational decision rules apply; indicates 2009 The Joint ommission
More informationHealthcare-Associated Infections (HAI) Quality Improvement Activity Project Kickoff Webinar
Healthcare-Associated Infections (HAI) Quality Improvement Activity 2017 Project Kickoff Webinar QIP PY 2019 Final Measure Domain Weighting Domain Weight Measures/Measure Topics Weight (Domain) Safety
More information2015 Executive Overview
An Independent Licensee of the Blue Cross and Blue Shield Association 2015 Executive Overview Criteria for the Blue Cross and Blue Shield of Alabama Hospital Tiered Network will be updated effective January
More informationIMPROVING TRANSITIONS FROM ACUTE CARE TO REHAB: SPREADING CHANGE ACROSS GTA HOSPITAL SITES FOR PATIENTS POST-HIP FRACTURE
IMPROVING TRANSITIONS FROM ACUTE CARE TO REHAB: SPREADING CHANGE ACROSS GTA HOSPITAL SITES FOR PATIENTS POST-HIP FRACTURE GTA Rehab Network Charissa Levy, Sharon Ocampo-Chan, Donna Renzetti October 2016
More informationPerioperative management of the higher risk surgical patient with an acute surgical abdomen undergoing emergency surgery
CLINICAL GUIDELINE Perioperative management of the higher risk surgical patient with an acute surgical abdomen undergoing emergency surgery CG10214-2 For use in (clinical areas): For use by (staff groups):
More informationAntimicrobial stewardship in Scotland: quality improvement agenda
Antimicrobial stewardship in Scotland: quality improvement agenda Dr Jacqueline Sneddon Project Lead Scottish Antimicrobial Prescribing Group Background Scottish Antimicrobial Prescribing Group (SAPG)
More informationImproving Outcomes for High Risk and Critically Ill Patients
Improving Outcomes for High Risk and Critically Ill Patients KP Woodland Hills Medical Center Presented by: Sharon M. Kent RN BSN, CCRN Lynne M. Agocs-Scott RN MN, CCRN CCNS Introduction of the IHI The
More informationB.S.N., M.S., CRNI, CNSN
Central Line Infection: Improving our Surveillance, Treatment and Prevention in the Home Setting By Susan Poole, B.S.N., M.S., CRNI, CNSN For as long as patients have had central venous catheters (CVCs),
More informationNational Priorities for Improvement:
National Priorities for Improvement: Standardization of Performance Measures, Data Collection, and Analysis Dale W. Bratzler, DO, MPH Principal Clinical Coordinator Oklahoma Foundation Contracting for
More information