Hospital Story Susan Bukunt, RN, MPA, CPHQ, Senior Director of - PowerPoint PPT Presentation

Hospital Story Susan Bukunt, RN, MPA, CPHQ, Senior Director of Clinical Quality & Patient Safety El Camino Hospital Mountain View, California

Objectives and About Us • 300 Beds- Mt. View • 143 Beds- Los Gatos • 443 total beds • 2800 employees • 1500 physicians • Magnet Status • Joint Commission • Certified Stroke Center • Certified Total Joint Hip & Knee • Certified Hip fracture • Accredited Chest Pain Center 2

Team Formation • PI Teams are formed on the recommendation of the Quality Council or the PI/Patient Safety Committee – Hospital concerned about the number of reportable Hospital Acquired Stage 3&4 Pressure Ulcers that were being reported – Decided to take decreasing HAPU as an organization wide annual quality goal – Formed a Team with Nurses, Clinical Nurse Specialist, Dietitian, Pharmacist, 3

Team Formation 4

AIM and Measure Selection • Decrease stage 3&4 HAPU from 2011 rate of 4.5/10,000 patient days to 2.55 by June 30, 2012 – Reportable to California Department of Public Health – Reviewed evidence based literature – Participated in local collaboratives 5

Tests of Change • Reeducation of Staff on identification and early intervention • Research study on silicon dressing with implementation • Wound Care Wednesday with “what is wrong with this picture” • RCA for any Stage II HAPU • Focus on intervention with MIST therapy 6

AIM and Measure Selection 7

Tests of Change 8

Barriers, and How We Resolved those Barriers • Everyone starts with reeducation, usually does not result in improvement • Needed team to be on the units not in a meeting room • Cannot get staff off unit for education , use huddles and roving carts to communicate TOC • Involve individual bedside nurses in the TOC • Difficult to get the message out and get everyone involved 9

Advice for Fellows • Make test of change small and targeted • Always look at what you can do by next Tuesday • Define metrics for success up front • Celebrate small successes, the larger picture can be overwhelming • Be willing to get rid of a change that has no value • Make sure you have tools that give you consistent documentation of progress 10

Results

Wrap Up and Next Steps • Summary • Achieved 2012 goal, reset goal to 1.99/10,000 patient days for 2013 • Next Tests of Change (TOC) • EMR triggering use of padded O2 tubing in patients on O2 over 48hours • Questions? 12