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

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• 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

Team Formation

• PI Teams are formed on the recommendation
• f 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

• rganization wide annual quality goal

– Formed a Team with Nurses, Clinical Nurse Specialist, Dietitian, Pharmacist,

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Team Formation

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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

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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

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AIM and Measure Selection

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Tests of Change

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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

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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

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Results

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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?