Expedition Coordinator

Transcription

1 Tuesday, July 30, 2013 These presenters have nothing to disclose IHI Expedition Impacting Hand Hygiene at the Front Line Session 1 Lisa Maragakis, MD, MPH Tom Talbot, MD, MPH Diane Jacobsen, MPH, CPHQ SiewLee Grand-Clément, RN, MSN, CPHQ Expedition Coordinator 2 Kayla DeVincentis, CHES, Project Coordinator, Institute for Healthcare Improvement, currently manages web-based Expeditions and the Executive Quality Leaders Network. She began her career at IHI in the event planning department and has since contributed to the State Action on Avoidable Rehospitalizations (STAAR) Initiative, the Summer Immersion Program, and IHI s efforts for Medicare-Medicaid enrollees. Kayla leads IHI s Wellness Initiative and has designed numerous activities, challenges, and educational opportunities to improve the health of her fellow staff members. In addition to implementing the organization s first employee health risk assessment, Kayla is certified in health education and program planning. Kayla is a graduate of Northeastern University in Boston, MA, where she obtained her Bachelors of Science in Health Science with a concentration in Business Administration. 1

2 WebEx Quick Reference 3 Welcome to today s session! Please use chat to All Participants for questions For technology issues only, please chat to Host WebEx Technical Support: Dial-in Info: Communicate / Join Teleconference (in menu) Raise your hand Select Chat recipient Enter Text When Chatting 4 Please send your message to All Participants 2

3 Chat Time! 5 What is your goal for participating in this Expedition? 5 6 Join Passport to: Get unlimited access to Expeditions, two- to four-month, interactive, web-based programs designed to help frontline teams make rapid improvements. Train your middle managers to effectively lead quality improvement initiatives.... and much, much more for $5,000 per year! Visit for details. To enroll, call or improvementmap@ihi.org. 3

4 What is an Expedition? ex pe di tion (noun) 1. an excursion, journey, or voyage made for some specific purpose 2. the group of persons engaged in such an activity 3. promptness or speed in accomplishing something Expedition Support 8 All sessions are recorded Materials are sent one day in advance Listserv address: HandHygiene@ls.ihi.org Sends an to all participants and faculty Use only for questions relevant to all participants To add yourself or colleagues, us at info@ihi.org 4

5 Where are you joining from? Expedition Director 10 Diane Jacobsen, MPH, CPHQ, Director, Institute for Healthcare Improvement (IHI) is currently directing the CDC/IHI Antibiotic Stewardship Initiative, NSLIJ/IHI Reducing Sepsis Mortality Collaborative. Ms Jacobsen served as IHI content lead and improvement advisor for the California Healthcare-Associated Infection Prevention Initiative (CHAIPI) and directed Expeditions on Antibiotic Stewardship, Preventing CA-UTIs, Reducing C. difficile Infections, Sepsis, Stroke Care and Patient Flow. She served as faculty for IHI s 100,000 Lives and 5 Million Lives Campaign and directed improvement collaboratives on Sepsis Mortality, Patient Flow, Surgical Complications, Reducing Hospital Mortality Rates (HSMR) and co-directed IHI's Spread Initiative She is an epidemiologist with experience in quality improvement, risk management, and infection control in specialty, academic, and community hospitals. A graduate of the University of Wisconsin, she earned her master's degree in Public Health-Epidemiology. from the University of Minnesota. 5

6 Today s Agenda 11 Ground Rules & Introductions Pre-Program Survey Results Call to Action for Hand Hygiene The Joint Commission Targeted Solutions Tool Using the Model for Improvement Action Period Assignment Ground Rules 12 We learn from one another All teach, all learn Why reinvent the wheel? Steal shamelessly This is a transparent learning environment All ideas/feedback are welcome and encouraged! 6

7 Overall Program Aim 13 To provide hospitals with practical change ideas and innovative approaches to impact Hand Hygiene at the frontline in their organization Expedition Objectives 14 By the end of the Expedition participants will be able to: Describe the impact of hand hygiene on healthcareassociated infections Discuss methods for measuring effectiveness of hand hygiene in your organization and creative approaches to assessing your progress over time Identify and begin improving at least one key process to increase hand hygiene focus and practice in your hospital 7

8 Schedule of Calls 15 Session 1 Call to Action for Hand Hygiene Date: Tuesday, July 30, 2:30 PM 4:00 PM ET Session 2 Measurement Approaches Date: Tuesday, August 13, 2:30 PM 3:30 PM ET Session 3 Supplies, Equipment, and the Environment Date: Tuesday, August 27, 2:30 PM 3:30 PM ET Session 4 Leadership and Culture for Hand Hygiene Date: Tuesday, September 10, 2:30 PM 3:30 PM ET Session 5 Frontline Engagement Date: Tuesday, September 24, 2:30 PM 3:30 PM ET Session 6 Marketing and Communications Campaigns Date: Tuesday, October 8, 2:30 PM 3:30 PM ET Faculty 16 Lisa Maragakis, MD, MPH is an Assistant Professor of Medicine at The Johns Hopkins University, Department of Medicine, Division of Infectious Diseases and the Hospital Epidemiologist and Director of the Department of Hospital Epidemiology and Infection Control at The Johns Hopkins Hospital. She received her medical degree and postdoctoral Infectious Diseases training at The Johns Hopkins University School of Medicine and a master s degree in public health from The Johns Hopkins University Bloomberg School of Public Health. She recently served as a Councilor on the Board of Directors of the Society for Healthcare Epidemiology of America (SHEA), as Vice-Chair of the SHEA Guidelines Committee and as the liaison representing SHEA to the Healthcare Infection Control Practices Advisory Committee at the Centers for Disease Control and Prevention. Her research interest is the epidemiology, prevention and control of healthcareacquired infections caused by antimicrobial-resistant gram negative bacilli. 8

9 Faculty 17 Tom Talbot, MD, MPH, FSHEA, FIDSA, Associate Professor of Medicine and Preventive Medicine, Vanderbilt University School of Medicine and Chief Hospital Epidemiologist, Vanderbilt University Medical Center, conducts research on healthcare epidemiology and infection control and oversees healthcareassociated infection prevention programs. Dr. Talbot currently serves as a member of the Centers for Disease Control and Prevention s Healthcare Infection Control Practices Advisory Committee (HICPAC). Pre-Program Survey Results Diane Jacobsen, MPH, CPHQ 9

10 Poll Question Who is in the room? 19 Please select the roles or departments represented on the call today from your organization. Check all that apply: Nursing Physicians Infection Prevention Quality Improvement Leadership Pharmacy Allied Health Professional Please chat any additional roles into the chat box. Survey Results: Top Barriers to Improving Hand Hygiene Lack of accountability or enforcement of compliance. 2. Staff are unaware of importance or proper procedure. 3. Leadership does not support hand hygiene campaigns or activities. 4. Sanitizer or sinks not reliably stocked and poorly located. 5. Staff are not engaged or supportive of hand hygiene activities. 6. Staff are too busy and do not have time to properly wash hands. 10

11 Survey Results: Measurement Approaches 21 Direct Observation Secret or Embedded Observers: 87% Unit Representatives Who Observe Own Unit Practice: 60% Sanitizer Consumption: 14% Healthcare-associated Infection Rate: 30% As a surrogate outcome Technology for Electronic Monitoring: 6% Including RFID Survey Results: Average Hand Hygiene Compliance 22 80% or greater 60%-80% 40%-60% Less than 40% Not sure 11

12 Call to Action for Hand Hygiene Lisa Maragakis, MD, MPH Healthcare-associated Infections and Resistant Organisms 24 Central line-associated bloodstream infections (CLABSI) Surgical Site Infections (SSI) Ventilator-associated pneumonia (VAP) Catheter-associated urinary tract infection (CAUTI) Methicillin-resistant S. aureus (MRSA) Vancomycin Resistant Enterococcus (VRE) Multidrug resistant Gram negative bacilli Clostridium difficile Influenza Respiratory Syncytial Virus (RSV) Varicella TB 12

13 How Do We Prevent HAIs and MDRO Transmission? 25 Hand hygiene Standard and isolation precautions Evidence-based best practices Surveillance/ data feedback Immunizations Cleaning, disinfection, sterilization Antimicrobial stewardship Hand Hygiene Indications Upon entering and exiting a patient room Between patient contacts if >1 patient in a room Before and after touching a patient who is not in a room (on a stretcher or wheel chair in the hall) Before donning and after removing gloves Before handling invasive devices After contact with blood or body fluids or excretions, mucous membranes, non- intact skin or wound dressings Any time needed such as after sneezing, or coughing before handling food or oral medications to patient room Before & after touching wounds Soap and water required AFTER care of patient on isolation for C. difficile or Norovirus 13

14 A Sobering Letter Today would have been my beloved wife s birthday. She died in your hospital I witnessed many gross violations... not limited to one building, one floor, or one individual. staff with colds coughing and sneezing in my wife's room without masks on doctors not washing their hands upon entering the room, they replied that these were simply guidelines, and that the staff person could opt to proceed at their own risk.. Best Practices to Prevent CLABSI Line Insertion Line Maintenance 1. Perform hand hygiene before and after catheter insertions or manipulation 2. Use chlorhexidine for skin preparation 3. Use full barrier precautions during insertion 4. Avoid using the femoral site in adult patients 2. Hub care 3. Site care 4. Tubing care 5. Assess the need for the catheter each day and remove ASAP 14

15 Best Practices to Prevent SSI Clean hands (surgical scrub) Use antimicrobial prophylaxis when indicated Right time (within 1 hour of incision) Right dose Right agent Appropriate duration Chlorhexidine skin prep applied correctly Clippers for hair removal (not razors) Control glucose and temperature Use appropriate FIO 2 Best Practices to Prevent VAP Hand hygiene Elevate the head of the bed >30 degrees Oral care with chlorhexidine Sub-glottic suctioning ET tube Sedation vacation Daily assessment of readiness to wean 15

16 Respiratory Etiquette Clean hands Cover your sneeze Get immunized (flu vaccine) Immunize your patients for flu and pneumococcus Wear a mask if you have a cold Do not work if you have influenza-like illness or any febrile respiratory illness Does hand hygiene work? YES!! Alcohol hand rub and old fashioned hand washing work well Reduces organisms on HCW hands Reduces infection rates Reduces mortality Doebbeling 1988, AIM:109;394-8 Larson 1988, ICHE:9;28-36 Pittet D, et al. Lancet 2000;356:

17 Ignaz Philipp Semmelweis ( ) Post-Partum Mortality Intervention Trial Two wards, each with 3500 deliveries/year Physicians and medical student mothers died/year Midwives 60 mothers died/year 20.0% 15.0% 10.0% Physician ward Midwife ward Intervention: Rub hands in chlorinated lime solution until slippery and cadaver smell gone before every vaginal exam 5.0% 0.0% Before After 17

18 Infection Rates with Improved Hand Hygiene Alcohol hand rubs and hospital-wide campaign to increase HH compliance Improved HH compliance (48% to 66%) Decreased MRSA incidence (2.16 to 0.93 episodes per 10,000 patient days) Overall healthcare-associated infections (17% to 10%) New MRSA per 100 admissions MRSA incidence Nosocomial Infections Infections per 100 admissions Pittet, Lancet 2000; 356: HH vs. MRSA Transmission Rate for JHH Adult ICUs October 2007 to June 2010 MRSA Transmission Rate Per 1,000 Pt. Days % 90% 80% 70% 60% 50% 40% 30% 20% 10% Hand Hygiene Compliance 0 Oct-07 Nov-07 Dec-07 Jan-08 Feb-08 Mar-08 Apr-08 May-08 Jun-08 Jul-08 Aug-08 Sep-08 Oct-08 Nov-08 Dec-08 Jan-09 Feb-09 Mar-09 Apr-09 May-09 Jun-09 Jul-09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 0% MRSA Rate (Per 1,000 Pt Days) Linear (MRSA Rate (Per 1,000 Pt Days)) HH Compliance Linear (HH Compliance) 18

19 Hand Hygiene Compliance by Profession Profession Compliance Registered Nurses 26% Physicians 21% Nurses Aides 14% Respiratory Therapists 10% Radiology Technicians 0% Environmental Staff Services 0% Medical Students 83% Kim P. Am J Infect Control April 2003 Why is Compliance So Poor? Skin dryness and irritation with frequent washing No time to wash hands (too busy) Inconvenient sink location Adherence not typically tracked individually no records kept Not rewarded Adverse events aren t immediate and their relationship to the missed HH opportunity isn t always clear Pittet, Ann Intern Med, Jan 19, 1999; Boyce Editorial 19

20 Another Sobering Letter. Dear Editor: The editorial on hand washing calls for all hospital staff to start regularly washing their hands between each patient contact. If, as the authors claim, there is such compelling evidence for the need to wash hands between each patient contact then why do I and the vast majority of my colleagues not do it? Firstly, I have never seen any convincing evidence that hand washing between each patient contact reduces infection rates. Secondly... Washing hands between each contact (at 1-2 minutes per wash) would take on average 1-2 hours. Where will this time come from, and who will fund it? If hand washing is to be performed between every patient contact then it would have major resource implications. For this it needs to be shown to be effective and worth the 15% extra staffing that would be needed to cover the extra time. -Andrew Weeks, specialist registrar in obstetrics and gynaecology BMJ 1999 Correlation Between High Workload and Lower HH Compliance Ward opp/ hr care ICU 43 opp/ hr care Decrease of compliance by 5% per 10 opportunites per hour Pittet D. Ann Intern Med

21 So is there any good news?? Yes! Multifaceted interventions; rigorous monitoring and feedback; rewards, recognition, and accountability can lead to improvements and good HH performance Improvement requires perseverance, dedication, engagement, leadership support, creativity and adaptability Hand Hygiene Compliance for JHH: January 2009 May % 90% CY 2013 Goal: 90% Hospital Mean: 91% 80% Hand Hygiene Compliance 70% 60% 50% 40% 30% 20% 10% 0% 21

22 Hand Hygiene Is the cornerstone and of upmost importance to our infection prevention efforts Leads to decreased HAIs and MDRO transmission Is difficult BUT POSSIBLE to achieve SHEA, IDSA and their partners are in the process of updating the Compendium of Strategies to Prevent Healthcare-associated Infections which will include a new section on Hand Hygiene Questions? 44 Raise your hand Use the Chat 22

23 Faculty 45 Siew Lee Grand-Clément, RN, MSN, CPHQ, Center Solutions Development Director, the Joint Commission, leads solution development activities for the Joint Commission Center for Transforming Healthcare. A Black Belt in Robust Process Improvement, she also serves as an RPI instructor and Mentor of Yellow Belts, Green Belts, and Black Belts. Prior to her current role, Siew Lee was the Associate Director of International Accreditation for Joint Commission International (JCI). Siew Lee brings extensive experience and diverse knowledge in nursing, staff training and development, and healthcare quality to her role at the Joint Commission. She has worked in multiple adult clinical areas in both small community hospitals and large academic medical centers. Siew Lee received her Bachelor of Science in Nursing with a minor in Community Health from University of Central Oklahoma, and her Master of Science and Advanced Practice Nursing training from Johns Hopkins University. The Joint Commission Center for Transforming Healthcare Hand Hygiene Targeted Solutions Tool (TST) 23

24 Introduction to CTH-Vision One Vision All people always experience the safest, highest quality, best-value health care across all settings. 47 Introduction to CTH- Mission Leadership The responsibility of leadership to make high reliability the priority Safety Culture RPI The importance of creating a culture of safety within an organization The use of proven quality methods Lean Six Sigma & Change Management (known together as robust process improvement ) to systematically improve processes and avoid common, crucial failures Our Mission: Transform health care into a high reliability industry and to ensure patients receive the safest, highest quality care

25 Robust Process Improvement (RPI) Systematic approaches to problem solving proven in many other spheres of work Lean, six sigma, change acceleration, Toyota Different from what came before (CQI, TQM) Equally effective when applied to our toughest safety and quality problems Directly address critical failings of current QI Appealing to physicians and other clinicians New Generation of Best Practices: Complex processes require RPI to produce solutions customized to an organization s most important causes Many causes of the same problem Key causes different from place to place RPI Each cause requires a different strategy 49 Project 1: Improving Hand Hygiene Compliance Virtua Wake Forest Trinity Health Cedars- Sinai Joint Commission CTH Black Belt & Master Change Agent Memorial Hermann Exempla Johns Hopkins Froedtert Each letter = one hospital 50 25

26 Confidential Easy to Use No Extra Cost SPREAD MECHANISM Separate from Accreditation Educational, no jargon, no special training and no knowledge of RPI methodology needed Guides users to customized solutions. Data analysis conducted by the tool, not the user. Tool walks user through process of: Measuring current state Determining root causes Selecting targeted solutions Control of process after implementation 51 Highly Reliable Solutions Healthcare Avoidable Conditions In TST In Progress CLABSI Adverse Drug Events Pressure Ulcers Injuries from Falls CAUTI Ventilator Associated Pneumonia Surgical Site Infections Venous Thromboembolism Obstetric Adverse Events Preventable Readmissions X X (new: heart failure) X X X X X X 52 26

27 Hand Hygiene Value Impact Study Over One Million Observations! 54 27

28 Analysis of Results Overall Hand Hygiene Compliance, US and International June 19, 2013 Percent Change in Compliance: 71% Improvement Percent Change in Compliance: 43% Improvement Percent Change in Compliance: 34% Improvement 100% 90% 80% 70% 60% 50% 48% 81% N = 503,991 83% N = 101,179 58% N = 12,184 64% N = 12,643 47% 40% 30% 20% 10% 0% Participating Hospitals (First 8) TST US Health Care Organizations TST International Health Care Organizations Baseline Post Improvement 55 Center Update -55 Hand hygiene For a typical 200-bed hospital, the TST for hand hygiene could save 8 lives and $2.3-$2.8M per year TST can prevent ~65-70 HAIs for every 100 beds A typical 200-bed hospital can expect significant benefits by implementing the TST tool # of HAIs / 100 beds / year Before TST After TST Number of HAI cases that could be prevented HAIs have a 5.8% mortality rate 8 8 Lives could be saved HAIs cost $18-21K per infection in direct medical costs 6 $ million Costs that could be saved Note: ( ) Assumes a 35% reduction in HAIs through a hospital-wide implementation of the TST for hand hygiene, based on the impact of 5 published studies (Refs 1-5) Sources: [1] Pittet (2001) J Hosp Inf, S40-S46; [2] Lam (2004) Pediatrics, e ; [3] Won (2004) Inf Cont Hosp Epid, ; [4] Pessoa-Silva (2007) Pediatrics, e382-e390; [5] Rosenthal (2005) Am J Inf Cont, ; [6] Figures adjusted to 2011 dollars using consumer price index - CDC "The Direct Medical Costs of Healthcare-Associated Infections in US Hospitals and the Benefits of Prevention," R. Douglas Scott II, March 2009; [7] Based on 1.7M HAIs contracted annually and 944K US hospital beds AHA, 2011 [8] CDC HAI mortality rate of 5.8% 56 28

29 Demo of Hand Hygiene 57 TST Step 1 Getting Started Tips from Experts 58 29

30 Defining Hand Hygiene -2 moments Link to CDC & WHO guidelines 59 TST Step 2 Training Observers 60 30

31 Downloadable training materials/ videos & competency exam Scenario videos and practice with the data collection form 61 Purpose Data collected Who Data Collection Method HH data collector (observer) To be an unbiased observer for hand hygiene compliance. Hand hygiene compliance data is used for establishing the baseline Hand Hygiene performance Secret shoppers : anonymous observers collected data on physical barriers of non-compliance without influencing the observed behaviors. Using staff in a position where they can secretly observe staff while performing their regular job duties and not seem out of place during their time on the unit. Example: housekeeping and lab staff, chaplains, volunteers. Just-in-time coach To intervene when hand hygiene noncompliance is observed and coach staff on proper compliance. Data collection will begin after the baseline data has been collected and the compliance data shared with staff. JIT coaches capture non-observable cultural barriers by interviewing health care providers after an observed instance of non-compliance. Approach staff when defects (noncompliance) occur and have staff to explain how the defect occurred since some defects cannot be observed (i.e., distractions, skin irritation). Example: unit managers, charge nurses, infection control practitioners, executives/leadership, and quality coaches or unit-based educators

32 TST- Step 3 Measuring Compliance Observable versus Non Observable Contributing Factors 63 TST Step 4 Determining Factors Real-time Analysis & data feedback Filtering capabilities to drill down for root causes 64 32

33 TST Step 4: Validated Contributing Factors Gloves Hands Full of Supply Follow Exit/Entry Frequent Exit/Entry Hands Full of Supply Follow Exit/Entry Gloves Distracted 65 TST Step 4: Driving Acceptance & Accountability Analysis of Mean: Wash IN & Wash OUT Compliance by Health Care Provider 66 33

34 TST Step 5: Implementing Solutions Targeted Solutions to Root Cause 67 Downloadable Solutions Guide Project checklist Implementation guide 34

35 TST Step 6: Sustaining the Gains 69 Memorial Hermann s Story: Getting to Zero Leadership committed to high reliability Embarked on culture change initiative MH Woodlands Hospital was among the 8 Center hospitals in first hand hygiene project 2010: MH committed to use TST to improve hand hygiene system-wide (12 hospitals) Baseline (150 inpatient units) = 44% Range (12 hospitals): from 21% to 65% Aim: to exceed 90% 70 35

36 71 Memorial Hermann: Summary System-wide HAI reductions using TST Baseline Control (pre-tst) (post TST) Relative Oct Jan-June Decrease May (%) Adult ICU BSI NICU BSI VAP BSI per 1000 line days 2 VAP per 1000 ventilator days 72 36

37 Michael Shabot, MD Memorial Hermann System CMO We fully attribute to the Center for Transforming Healthcare s hand hygiene [tools] the final drop in HAI rates to zero or near-zero system-wide. After implementing CTH hand hygiene, our hospitals began to report zeros as their most common monthly CLABSI and VAP result. Our mothers were right after all! Feel free to quote me. This actually saves lives. 73 International Hand Hygiene TST pilot cohort Europe (2): 1. Azienda Ospedaliero Universitaria (S Maria della Misericordia) di Udine, Udine, Italy 2. UZ Leuven, Leuven, Belgium Asia Pacific (3): 1. The Medical City, Pasig City, Philippines 2. Institute Jantung Negara in Kuala Lumpur, Malaysia 3. Premier Jatinegara Hospital, Jakarta, Indonesia Middle East (4): 1. National Center for Cancer Care & Research, Doha, Qatar 2. King Faisal Specialist Hospital & Research Centre, Jeddah, Saudi Arabia 3. King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia 4. Sheikh Khalifa Medical City, Abu Dhabi, UAE 74 37

38 How do I Access the TST? 75 Using the Model for Improvement Diane Jacobsen, MPH, CPHQ 38

39 Model for Improvement What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement? Aim of Improvement Measurement of Improvement Developing a Change Act Study Plan Do Testing a Change Adapted from Langley, G. J., Nolan, K. M., Nolan, T. W., Norman, C. L., & Provost, L. P. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. San Francisco, CA: Jossey-Bass, Why Test? Increase the belief that the change will result in improvement Predict how much improvement can be expected from the change Learn how to adapt the change to conditions in the local environment Evaluate costs and side-effects of the change Minimize resistance upon implementation 39

40 79 Act Decide changes to make Arrange next cycle Study Complete data analysis Compare to predictions Summarize learning Plan Compose aim Pose questions/predictions Create action plan to carry out cycle (who, what, when, where) Plan for data collection Do Carry out the test and collect data Document what occurred Begin analysis of data Testing on a Small Scale RULE OF ONE: Conduct the test on one unit, with one staff member or physician and one patient Conduct the test over a short time period Test the change on a small group of volunteers Develop a plan to simulate the change in some way 40

41 Repeated Use of the PDSA Cycle Sequential building of knowledge under a wide range of conditions A P S D Changes That Result in Improvement Spread Implementation of Change Hunches Theories Ideas A P S D Very Small Scale Test Follow-up Tests Wide-Scale Tests of Change 81 Questions? 82 Raise your hand Use the Chat 41

42 Action Period Assignment 83 Complete 3 to 5 hand hygiene observations on one unit using the data collection tool provided by the Joint Commission (will be distributed on the listserv after the call) OR your organization s current data collection tool If using the Joint Commission tool, Watch Improving Care with Targeted Solutions Tool (TST) video (6 minutes) g-care-with-the-tst/ Based on what you observed, brainstorm ideas you could test to address current barriers to hand hygiene Consider: visibility and availability of soap, visual reminders or prompts, workflow obstacles related to availability and location of supplies, pace on the unit, etc. Come prepared to share your experience at Session 2. How do I Access the TST? 84 42

43 Expedition Communications 85 Listserv for session communications: To add colleagues, us at Pose questions, share resources, discuss barriers or successes Next Session 86 Tuesday, August 13, 2:30 PM 3:30 PM ET Session 2 Measurement Approaches 43