Transcript Lessons Learned Root Cause(s)?

Transforming Care at the Bedside
across Wisconsin
Monthly Webinar for January
The 90 day Challenge!
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Welcome to Today’s Call
 Agnesian St. Agnes
 Aurora Burlington
 Aurora Lakeland
 Aurora Sinai
 Calumet Med Ctr
 Fort Health Care
Froedtert Comm Mem:
 Ortho
 Medical
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Froedtert Milwaukee
Hayward Area Memorial
Howard Young Med Ctr
Mayo – Eau Claire
Mayo – LaCrosse
Mercy Janesville
Wm S Middleton VA
Midwest Ortho Spec H
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The Richland Hospital
Spooner Health System
St. Croix Regional Med Ctr
St. Elizabeth Hospital
Tomah Memorial H
Westfield’s Hospital
Wheaton Fran - Franklin
Zablocki VA Hospital
Please confirm your hospital is in attendance
(if you miss roll call – please e-mail Stephanie by 4 pm)
2
Today’s Agenda
1. Announcements
– Site Visit Update from Judy
– CNO Reports and Innovation Logs
2. 90 Day Challenge Slides
3. Upcoming Webinars
3
TOPIC: SICU Pain Improvement Score
DATE: Jan. 3, 2014
HOSPITAL: Froedtert Hospital Milwaukee
Aim Statement:
1.
Lessons Learned
Measure
2013 SICU Avatar Score
What was your 90 day aim?
Increase Avatar pain score by .2%
from 85.85 to 86.05 in 90 days.
For ICUs, Avatar is similar to
HCAPS score but consists of
only four questions. The
question related to pain is
“Given my medical condition, I
was satisfied with how well my
pain was controlled in SICU”
“Given my
medical
condition, I
was satisfied
with how my
pain was
controlled in
SiCU”
Root Cause(s)?
What is the cause of the
problem?
-
There are only four questions
related to a patient’s stay in
the ICU. The “N” ( total
number of returned survey )is
low. One negative reply
affects the total score.
1
Briefly describe tests and trials
poster developed on pain scales: placed in
staffroom for staff to read
2
e-mailed nurse reminders to reassess pain after
medication admin
Difficult to totally relieve pain
in certain populations
(trauma, intubated waiting to
be extubated, brain injury
requiring neuro assessments)
3
RAAPS (pain team) presented at staff meeting
to discuss acute on chronic pain and
management of both
4
pain reassessment audit from Joint Commission
tool
5
TCAB members writing patient pain goals on
white board in patient room when applicable
-
Pain reassessment not
documented as indicated by
audits
What will be done differently
as a result of this
improvement process
1) more attainable goal for the
TCAB group for a 90 day
challenge
2) Difficult to do a “quick fix” on a
long term problem in short
time span
3) SICU will continue to strive for
improved pain score (look at
follow up)
Test Cycles
1.
-
1.
Follow Up
1.
1)
2)
3)
4)
5)
What are the next steps?
Posting trend of Avatar pain
score
Re-education at: staff meetings,
newsletter, posting in report
room
Utilization of pain info on white
board in patient room’s:
laminated pain verbiage on white
board along with pain score
Developing a “script” to reflect
the Avatar pain question on
4
survey
Updating patient education
booklet to reflect Avatar
statement
BEDSIDE REPORT
JANUARY 2014
Fort Healthcare
Aim Statement:
Lessons Learned
Measure
In 90 days increase patient safety and
communication through consistently
doing bedside reporting.
Place Run Chart or Graph
here
1.
It does not take longer to do
bedside report.
2.
Patients and families like it and
feel like they are participating in
their plan of care.
3.
Increase in “near-misses” caught
in a timely manner (ex.; Iv abx not
infusing, bed alarm off, scd’s off,
infiltrated IV sites, etc.)
Follow Up
Root Cause(s)?
1.
Lack of patient participation in plan
of care.
2.
Inefficiency of staff time during shift
change.
3.
Safety issues related to clarity
events.
Test Cycles
1.
Leadership to continue
patient rounding for patients
feedback on bedside report.
2.
Implement Inpatient Services
Folder containing
information about bedside
report to be given to patients
on admission.
1
CNO memo sent to nursing staff
2
SWANK education for nursing staff
3.
UBC to continue to
encourage staff to participate
in bedside report.
3
CPC developed Policy & Procedure for performing
bedside report
4.
Monitor if decrease in patient
falls
4
UBC designed template for nurses to utilize
5.
Monitor clarity events for
near-misses.
5
Nursing leaders surveyed patients about if staff were
performing bedside report
5
TOPIC: Nursing Vitality Scores
DATE:01/07/2014
HOSPITAL: Agnesian Healthcare (SAH)
Lessons Learned
Measure
Aim Statement:
1.
What will be done differently as a
result of this improvement process
1.Increase Vitality score by 1-2%
1.What will be done differently as a result
of this improvement process
•Work on projects that are quick wins if
the end date is 3 month.
•Bring in the other disiplines early to get
their feedback.
•Increase awareness for the associates
working through the process. Often
reminders of the change implimented.
Root Cause(s)?
Test Cycles
1.What is the cause of the problem?
•Associates not working as a team
•Staff turn-over
•Too many “hoops” to implement
changes
•IT issues with Advanced Care
Documentation
1
Trialed Break Buddies
2
Volunteers to sit with patients as a companion
3
Compliment Hot-Line
4
Medication Information Sheets
5
Follow Up
1.
What are the next steps?
Implement Break Buddies on all the
units.
•Work with volunteer Services to
implement a partnership to help with
patients that need to talk or want
companionship.
•Encourage nurses to use the new
medication sheets routinely.
•Continue to try to get a Compliment
Hotline started
6
TOPIC: Pain Menu
DATE: 1.7.2014
HOSPITAL: Froedtert- Community Memorial Ortho
Aim Statement:
Lessons Learned
Measure
1.
1.
What was your 90 day aim?
During post discharge
phone calls we have
asked patient’s if they
felt they understood all
pain options provided to
them.
To increase patient’s awareness of ALL
pain options, both pharmacological and
non pharmacological.
What will be done differently as a
result of this improvement process
More feedback from patients versus just
asking yes/no questions.
Root Cause(s)?
1.
Test Cycles
What is the cause of the problem?
Being an orthopedic unit, pain
management is always a concern. Pain
control is also a strategic goal for our
organization. Ortho TCAB wanted to do
something that would focus on
improving patient’s pain while they were
inpatient and even when they go home.
1
TCAB met in beginning of November to design the
content for the pain menus
2
TCAB members took the mock pain menus back to
staff to see if changes should be made
3
Phone calls made to discharged patients for two
weeks in November. (11/6-11/22)
4
Pain menus used on the unit starting 11/20
5
Follow up phone calls made again December 4th-18th
Follow Up
1.
What are the next steps?
Continue to use the pain menus and
spread the word to the rest of the
hospital
7
TOPIC: Bedside Report
DATE: January 2014
HOSPITAL: Westfields Hopsital
Aim Statement:
1.
Lessons Learned
Measure
What was your 90 day aim?
1.
This is still a work in progress
2.
Readdress the importance of this
newly adapted bedside report and
the impact it has on patient
satisfaction
Our focus was to continue with
bedside reporting and each 30
days we would reevaluate, make
necessary adjustments and
continue forward.
We wanted to include what our
patient satisfaction scores were
Root Cause(s)?
Test Cycles
1.
Patient satisfaction is high, not
enough nursing staff support
2.
Old habits die hard – continuing
with more verbal report
1
Full bedside report with both RN’s and patient/ family
in patient’s room
Not enough understanding of
importance to patient and family
for bedside report
2
RN shift summary introduction to nursing staff and
removal of verbal report in patient room and replacing
with computerized written handoff
3
Meet and greet in patient’s room with both RN’s,
introduction of nurse and update to care board,
questions/ concerns
4
Implementation of RN shift summary + meet and greet
3.
5
Follow Up
1.
Encourage staff to continue with
bedside report
2.
Revisit new word/ phrases to use
when taking care of same patient
over time
8
TOPIC: Hourly Rounding
DATE: 12-19-13
HOSPITAL: St Croix Regional Medical
Aim Statement:
Lessons Learned
Measure
CALL LIGHT STUDY OCTOBER 2O13
What was your 90 day aim?.
What will be done differently as a
result of this improvement process
45
1.
To Develop a plan for
Implementing Purposeful
Hourly Rounding on the
Med-Surg unit.
Percentage of Total Calls
40
35
20
2.
It was difficult to match the
RN and NA so that their
schedules and job duties
matched the rounding
schedule.
42
15
10
20
10
8
6
5
4
3
2
Reposition
Other
Food/Water
Accidental Call
Hygiene
0
Bathroom
IV pump
beeping
Bed alarm
Medications
(Pain or other)
Reason
Root Cause(s)?
Unsuccessful Implementation of
Hourly Rounding in the past.
Was not a team approach,
but focused as a Nursing
Assistant responsibility.
Found through our call light
study that the majority of the
call lights were due to
patients needing to use the
bathroom, IV pump alarms
and bed or tab alarms.
25
5
What is the cause of the problem?
1.
30
Test Cycles
1
Call light study
2
Trial of 1 RN and 1 aide team doing
purposeful hourly rounding together.
3
Discussions at staff meetings to get input
from staff on ways to successfully implement
hourly rounding.
4
Discover what barriers exist and any
solutions to those barriers.
5
Have all care boards hung in patient rooms
to use
Follow Up
What are the next steps?
1- Develop 6 teams of RN’ s and
aides that work together on
the weekends to do another
trial of rounding to find more
barriers or successes to our
rounding.
2- Develop a rounding schedule
for the staff to be able to
visualize with times to keep
9
on track.
TOPIC: Observation Patients and Problems
Associated with the Use of Home Meds
DATE: January 3, 2014
HOSPITAL: Aurora Lakeland Medical Center
Aim Statement:
Lessons Learned
Measure
1.
1.
What was your 90 day aim?
Implement a process for the
identification and administration
of home meds in the
observation patient. This is to
include the appropriate storage
of the meds and subsequent
return to the patient at
discharge while the patient is
hospitalized.
Formation of an interdisciplinary
team to address designated
storage area and process for
ensuring that the patient is
discharged with their home meds.
Root Cause(s)?
1.
What will be done differently as a
result of this improvement process
Follow Up
Test Cycles
What is the cause of the problem?
1.
1
Staff perceptions
2
Pharmacy interaction
3
Storage capabilities
4
Patient satisfaction with the
current process
5
What are the next steps?
Creation of a formal process
to address the
issues/barriers of home
meds in the observation
patient
10
TOPIC: Medication Education
DATE: 1/06/14
HOSPITAL: Mayo Clinic Health System
La Crosse
Aim Statement:
1.
Measure
Increase HCAHPS scores for
teaching patients what new
medications they are taking
are for from 75% to 79% and
teaching patients about side
effects of medications they
are on in a way they can
understand from 48% to
50%.
Root Cause(s)?
1.
2.
There was no standard way
to educate patients about
new medications they were
taking and side effects of
medications they were
taking.
Completed HCAHPS
education for staff at unit
meeting and completed and
A3 with RN’s at each unit
meeting.
Test Cycles
1
2
One RN got list from pharmacy of common
medications given on our unit. Created an
education sheet with medication name, what it is
used for, and side effects. Used this for one
patient- got feedback if patient could take home
with them.
One RN used to educate on 2 patients, received
feedback about wording. Let oncoming staff know she
was trialing this with the patients.
3
Made some changes to wording. One RN used on 3 of
her patients, and had another RN try on her patients.
4
Two RNs continued to trial on their patients. All
patients like format, thought information was good and
easy to understand.
Lessons Learned
1.
On admission each patient will
receive a medication information
sheet with common medications
listed, what they are used for and
possible side effects in an easy to
understand format in their
admission folder.
2.
It is the nurses responsibility each
shift to look at the education sheet,
highlight and educate about any
medications the patient is taking.
3.
The patient is able to take that
education sheet home with them.
4.
Data varies, depends on number of
respondents, takes around 3
months to be accurate. Watch for
consistency.
Follow Up
1. Approval from hospital
Education Council
2. Brand education sheets.
3. Educate all staff.
4. Add education sheets to
admission folders.
11
TOPIC: Increase Time at the Bedside
DATE: 12/28/2013
HOSPITAL: Aurora Sinai
Aim Statement:
Lessons Learned
Measure
70
1.
Aim was to increase time at
bedside to 60%.
60
50
2.
Goal was met, 61% of RN’s
time was spent at the
bedside
40
30
20
10
Root Cause(s)?
1.) Supplies and equipment issues
2.) Time management
3.) Poor shift to shift report/
transition
0
Oct12
J a n13
A pr13
J ul- 13
Oct13
% a t B e ds ide
Follow Up
Test Cycles
4.) Reluctance to change
5.) MD’s rounding on patients
without nursing staff
1.) Focus again on supplies and
equipment. Are they
available, in working
condition and readily
accessible.
2.) Need to continue to enforce
real time charting in rooms.
3.) Need to work on bedside
reporting at shift change.
Some staff are willing to try
it and adopt it, while others
still are reluctant.
4.) Hourly rounding has been
adopted and is working.
5.) Implement rounding with MD’s
and nursing staff when
rounding on patients.
1.) Re-introduced Bedside reporting with
RN’s and purposeful rounding
-Staff willing to adapt and adopt
2.) Hourly rounding
-Adopted and working
3.) Re-addressed supplies and equipment
issue
1.
Will repeat time study in one
month and see if the inventions we
have placed above will increase
our time at the bedside to 65%.
12
TOPIC: Medication Education Sheet
DATE: 1/7/2014
HOSPITAL: Tomah Memorial Hospital
Aim Statement:
1.
Lessons Learned
Measure
1. What will be done differently as a
result of this improvement process
What was your 90 day aim?.
More medication education will
be given to patients which will
help increase our HCAHPS
scores and help decrease
readmissions.
By Dec. 31st we will improve
patients understanding of new
medication and increase at least
15% in HCAHPS Scores.
HCAHPS
Question
Root Cause(s)?
1.
Test Cycles
What is the cause of the problem?
Our HCAHPS survey scores for
questions 16, 17 and 25
concerning patient medication
education were unsatisfactory.
Our unit feels as though we could
always do more medication
education with patients. Some
reasons we haven’t been up to
par is due to poor education
material and not a lot of time to
teach.
1
Get top 25 most used meds for hospital and make up
sheets from that.( It takes 1+ months to get info)
2
Get sheets from Fort Hospital and revise to make our
own.
3
4
5
Have other departments help develop medication
education sheets.
Pam RN trialed quiet time/teaching time for a few
days. Come up with signs to inform staff and family
(still in progress)
Roll out quiet time/teaching time to unit and possibly
whole hospital.
*When we predicted our goals for
improvement we did not take into
consideration the lag time for
HCAHPS scores to be received.
We hope to see results with the
incoming scores in the next
couple months.
Follow Up
1.
What are the next steps?
Finish respiratory education
sheet.
Develop more medication
education sheets for other
classes of drugs or diagnoses.
Adopt, adapt, or abandon quiet
time/teaching time.
13
TOPIC: Bedside Shift Reporting
DATE: 1/2/2014
HOSPITAL: Froedtert Health: CMH - Med
Aim Statement:
Lessons Learned
Measure
1. Increased patient involvement
in plan of care enhances overall
patient satisfaction with nurse
communication.
1. By December 31, 2013, 75% of
patients will answer yes to a
question about participation in
planning their care.
According to collected data, 100%
of patients called feel involved in
their plan of care since
implementation.
Pre TCAB
Root Cause(s)?
1.
2.
Kardex
2.
Identify barriers to bedside
report prior to
implementation. Ours was
time, once this was decreased
it was an easier transition.
3.
You need a few dedicated
staff to keep the ball rolling
and people motivated to
continue bedside report.
Bedside
Test Cycles
Patients felt separate from the
care they were receiving.
Care was done “to them” not
“with them”.
1
Some important information
was being missed on patients
that were staying for long
periods of time.
2
Implement bedside report. Begin with small test
groups, increasing weekly to include all staff.
3
Hardwire process by prepping staff, patients; and
developing and defining criteria for bedside shift
report.
4
Obtain data including number of patient that
answered yes to “did you participate in planning
your care?” during post discharge phone calls.
Obtain baseline data including numbers of
patients that answered yes to “Did you
participate in planning your care?” during post
discharge phone calls.
Follow Up
1.
Auditing compliance and
use of bedside shift report
14
TOPIC: Patient Partnership/ Activity Log
DATE: Jan. 2014
HOSPITAL:
Midwest Orthopedic Specialty Hospital
Aim Statement:
Lessons Learned
Measure
80.00%
Improve partnership
with patients by use of
an activity log to
prevent post-op
complications. (IS,
flex/ext. ankle
exercises, CPM time,
up in chair,)
In 90 days, 50% of
patients will actively be
working on the log
during audits.
Root Cause(s)?
The activity log had
been included in
Welcome Folders
several years ago to
engage patients in
tracking activity goals,
but had not been
utilized.
1.
Not enough staff
participation. Patients too
sedated DOS to make use of
the log.
2.
Need more communication
& reminders to staff.
Patients are better able to
work on logs when m ore
alert on POD 1.
3.
Audit results more
frequently so changes can
be made to meet goals.
70.00%
60.00%
50.00%
40.00%
30.00%
20.00%
10.00%
Follow Up
0.00%
7-Nov
Cycle 1
20-Nov
5-Dec
7-Dec
11-Dec
Cycle 2
18-Dec
21-Dec
28-Dec
1.
Continue to audit more
frequently and provide
staff feedback.
2.
Add to SCIP checklist
3.
Monitor HCAHPS , Press
Ganey, & HAC reports.
Cycle 3
Test Cycles
1
1. Revised activity log. 2. laminate & keep on communication board
with clip. 3. Introduce to staff. 4. Explain log to patients &keep at
bedside. Initiate on DOS with first iS instruction. Audit patient rooms for
use of tool.
2
1. Attach velcro with dry erase markers to log. 2. Initiate tool POD #1 when pt.
more alert. 3. Audit patients POD #1 or > for use of tool Q2 weeks.
3
1. Reinforce at staff meeting. 2. Reminders on white board in employee work
room. 3. Audit patients POD #1 or > for use of tool 2x/week.
**Activity
Log
15
TOPIC: Break Buddies
DATE:
September 2013
HOSPITAL: MCHS-Eau Claire
Staff Who Take a Lunch
Break
What was your 90 day aim?
96.0%
Aug-13
Sep-13
99.4%
99.6%
98.7%
99.4%
98.0%
98.5%
100.0%
100.0%
99.0%
100.0%
97.4%
97.0%
95.8%
97.3%
In 90 days, increase the number
of staff that take a lunch break
with a goal of 99%
97.9%
97.9%
96.3%
97.8%
1.
Lessons Learned
Measure
Aim Statement:
Oct-13
Nov-13
94.0%
Changes were made in late September.
Root Cause(s)?
1.
RN
*Turnovers of patients (d/c,
admits, tx)
HUC
What will be done differently as a
result of this improvement process
• Assure break buddies are
assigned at every shift-Staff
are not actively taking breaks
unless held accountable by
break buddy
• Show staff data at monthly
staff meetings to support the
use of break buddies
Total
Test Cycles
What is the cause of the problem?
*Workload
CNA
1.
1
Break Buddies Assigned
2
Reminders posted around unit
3
LN rounding with each staff member
Follow Up
1.
What are the next steps?
* Data collection
*Interruptions
4
5
16
Patient Education Discharge Teaching
01/08/2013
Milwaukee VA Medical Center
Aim Statement:
Lessons Learned
Measure
1.
What was your 90 day aim?.
Our aim is to pilot a new process for
implementing patient discharge teaching
upon admission. It will be a detailed
process followed by all staff on the unit.
Percent of Discharge Learning Objectives Met by Veterans
Root Cause(s)?
1.
80
60
40
20
0
Test Cycles
What is the cause of the problem?
Currently, there is no standardized
process for determining discharge
teaching needs or timeframes for
completing discharge teaching.
What will be done differently as a
result of this improvement process
Discharge teaching will begin upon
admission instead of the day of
discharge. Also, there will be specified
teaching topics individualized to each
veteran based on their medical
conditions and teaching needs.
100
Percent of Discharge
Teaching Objectives Met
1.
1
2
3
Pilot to begin 02/10/2014- We will conduct the pilot
using four case studies, one per team on unit 9A.
Follow Up
1.
What are the next steps?
The next steps are to implement the pilot,
obtain feedback from staff, and make
adjustments based upon these
recommendations prior to full
implementation.
4
5
17
TOPIC: Team Vitality
DATE: 1/1/14
HOSPITAL: Spooner Health System
Lessons Learned
Aim Statement:
1.
What was your 90 day aim?.
Increase % of nurses who score
5/5 to the questions regarding
communication between shifts
and hand-off communication on
the Team Vitality Survey.
1.
Measure
a) Staff will stop chatting and wait
until the end of report for each
patient to ask questions.
Percentage of 5/5 responses
Shift Change
Patient Handoff
mo/yr
Info. Exchange
Info Exchange
10/12
32
24
03/13
25
5
10/13
25
15
Root Cause(s)?
(Will not have results of test until next survey)
What is the cause of the
problem?
Test Cycles
a) Hand off from ED to floor feels
rushed, not enough time to ask
questions.
b)Distraction is a large issue during
report and at handoff., especially
when sidebar conversations take
place.
c)unable to find reporting RN in a
timely manner to ask questions
after listening to taped report.
d)Information is not always
thorough during report.
e) Some staff give oral report and
others tape report.
1
2
Each TCAB members queried 2-3 nurses
“what problems/barriers in nurse
communication?” and “what ideas do you
have for improvement?”
Staff were interviewed regarding preference
for taped vs face to face report.
3
RN queried staff regarding pro’s/con’s of
verbal vs. taped report.
4
Designated RN at report sessions coached
staff over a 2 week period to not chat and to
wait until the end of report to ask questions.
b) Staff will ask how well a patient
is known thereby preventing
leaving out pertinent information to
new nurses
c)Recommend to expand use of
whiteboards in patient room to
communicate further info ie: fall
risk, activity level, diet, etc.
d)Recommend use of white board
for staff in report room.
Follow Up
1.
What are the next steps?
a) Coach/teach staff to use SBAR
during report.
b) Nursing Management to be
approached regarding option of
assignments, role of charge
nurse, use of staff white board.
c) Continue to investigate
pro’s/con’s of taped vs. verbal
18
report.
TOPIC: Bedside Report
DATE: Jan 2014
HOSPITAL: Mercy Hospital
Aim Statement:
1.
Increase bedside report
compliance by 50% on all
shifts through standardizing
bedside report process
Lessons Learned
Measure
1.
Share testimonials
from nurse to nurse
about benefits of
change process
2.
Temperature check of
unit and team prior to
implementing change
process
3.
Encourage and praise
4.
Share progress with
other departments
Place Run Chart or Graph here
Root Cause(s)?
1.
Miscommunication
2.
Lack of confidence
3.
Fear of change in process
4.
Misunderstanding of
process
Follow Up
Test Cycles
1
Brief survey to RNs regarding barriers and bedside
report satisfaction. Results shared with staff
1.
Continue temperature check
2.
Onboarding of new staff
2
Standardized time for bedside report to start 10
minutes after the start of each shift change
3.
Problem solving and
intervention
3
SBAR template to give report provided to all RNs
4.
Remain open to
improvements
4
Revised and simplified SBAR template
5
19
TOPIC: Medication Education
DATE: 1/2014
HOSPITAL: Richland Hospital
Aim Statement:
Lessons Learned
Measure
To improve patient
understanding of meds and
to increase HCAHPS scores
by 10% in the category
“Communication about
Meds”
Standard Teaching Documents
being used for our most used
medications.
30
25
20
Ind icat io n
15
D o sag e
Sid e Ef f ect s
10
5
0
Root Cause(s)?
Nurses are now able to see
medication education that is
being done with patients.
Better follow through on
medication education based
on the above.
Test Cycles
-Nurses doing routine med
teaching and patients not
realizing med teaching being
done. Need to come up with a
tool to use so patients realize
education is taking place and
so nurses can still complete
teaching in a timely manner.
-Hard to find documentation on
medication education
previous nurses have done
with patient
1)
Gathered Data: TCAB developed a med
question sheet to gauge how well patients
know their meds.
2)
Stole Shamelessly: Obtained med teaching
sheets from another TCAB team.
3)
Applied to Our Patient Population: Looked at
our primary population and diagnoses and
created med teaching sheets for our unit.
4)
Colloborated with Pharmacy and EMR:
Worked with our pharmacy director to produce
medication education sheets and EMR to build
documentation screens into Meditech.
Follow Up
1)
Implementation of Medication
Teaching Tool
2)
Continue EMR involvement as
they work to build a more
efficient way to document
med teaching in Meditech
3)
Monitor HCAHPS for
improvement
20
TOPIC: Increase ambulation to decrease falls
DATE: 1/7/2014
HOSPITAL: William S. Middleton Memorial VA Hospital
Aim Statement:
Lessons Learned
Measure
1.
1.
What was your 90 day aim?
What will be done differently as a
result of this improvement process
Consistent documentation of
ambulation in a specific section of
the nurse shift summary note as
identified by nursing and other
disciplines caring for the patient.
Increase purposeful patient
ambulation and staff awareness of
the need to ambulate through
standardized documentation.
Increased awareness which will
increase staff commitment to
patient ambulation
Root Cause(s)?
1.
Test Cycles
What is the cause of the problem?
Nurses had different perceptions
on where ambulation should be
documented
There was no guide of
measurement in the hallway to
assist staff with documentation of
distance
Follow Up
1
Chart audit was completed to identify where the
majority of staff documented ambulation
2
Ambulation was the focus of one staff meeting to
identify where ambulation would be documented.
3
All staff were educated on the standardization of
ambulation documentation
4
Markers were placed in the hallway to utilize as
guides of documentation
5
White boards are used to communicate ambulation
expectations and other disciplines involved in
decision of where to document
1.
What are the next steps?
Evaluate effectiveness in
ambulation program for those
patients that are high fall risk
21
DATE: 1/9/13
TOPIC: Break Buddies
HOSPITAL: St. Elizabeth Hospital
Lessons Learned
What will be done differently as a result
of this improvement process?
Measure
Aim Statement:
Continue to engage associates in a
supportive manner and listen to
their ideas
•
Management coach associates
who habitually miss their meal
break
•
Staff need to use scripting with
patients to inform them of the staff
break time and meet needs prior to
taking their break
•
Share the results with associates
regularly to track progress
TC
3
f
11
/1
7/
1
31
1/
3
/1
6
0/
1
/1
3
/1
3
11
/3
10
/2
0/
1
/1
311
31
/1
9
1/
2
/1
3
13
/1
310
10
/6
/1
310
9/
22
13
-9
/2
Root Cause(s)?
/5
/
1/
1
3
3
UC
7/
1
8/
25
2. Decrease dollars
paid to
employees for nolunch punches by
50%
•
RN
9/
8/
1. Decrease # of NoLunch punches
by 50%
40
35
30
25
20
15
10
5
0
/1
39/
What was your 90 day
aim?.
# of No Lunche Punches
No Lunch Punches by Pay Period
Follow Up
Pay Period
What are the next steps?
What is the cause of the problem?
Staff kept their phones with them
on break and were constantly
interrupted when trying to
have a 30 minute break
Staff needed to hand their phones
off to someone so they could
actually take a break
Staff required education on fatigue
and the importance of taking
a break
Test Cycles
1
2
3
4
5
•
Punching in and out during
lunch break to ensure all
employees have a 30 minute
uninterrupted break
•
Staff MUST hand-off phones
for break so we’ll purchase an
extra phone to use on breaks
for personal calls
•
Spread our progress with
other Ministry hospitals
Cycle 1: 2 RNS
Cycle 2: 4 RNS paired
Cycle 3: 6 RNS paired
Cycle 4: 6 RNS & 2 TCS paired
22
Cycle 5: 6 RNS, 4 TCS, UC paired
TOPIC: Nurse Server Stocking
DATE: January 2013
HOSPITAL: WFH-Franklin
1.
What was your 90
day aim?. To
decrease amount
of time that is
spent between
running and
gathering supplies
by stocking the
nurse server.
Lessons Learned
Measure
Aim Statement:
Step Count in 4 hours
1.
5000
4500
4000
3500
2.
Our keyholes were
not easy to use so for
new construction
looking at a different
options for locking
Step Count in 4 hours
mechanisms.
3000
2500
2000
1500
Nurse servers were
not stocked with the
most frequently used
supplies so staff
would spend a
greater amount of
time hunting and
gathering instead of
spending it with
patients.
Test Cycles
PCA 2
RN 2
PCA 2
RN 2
PCA 2
RN 2
PCA 1
PCA 1
PCA 1
0
Nurse 1
What is the cause of the
problem?
500
Nurse 1
1.
1000
Nurse 1
Root
Cause(s)?
Important to make
sure that locking
mechanisms on
nurse servers are
easy to use.
0700-0700-1100-1100-1500-1500-1900-1900-2300-2300-0300-03001100 1100 1500 1500 1900 1900 2300 2300 0300 0300 0700 0700
1
First came up with supplies most utilized at
the patient’s bedside.
2
Ordered and stocked bins for one room to
see if all the supplies were necessary .
3
Counted our steps prior to initiating for our
baseline data.
4
Stocked all room nurse servers and
implemented and planned a restocking
process.
5
Handed out keys along with a process to
pass to each shift.
Follow Up
1.
What are the next steps?
Is to gather our post
implementation step data
week of January 13th.
23
TOPIC: Fall Prevention
DATE: Jan 8
HOSPITAL: Aurora Memorial Hospital - Burlington
Aim Statement:
Lessons Learned
Measure
1.
1.
We will have no falls for 100
days.
Place Run Chart or Graph
here
Root Cause(s)?
1.
What is the cause of the problem?
Test Cycles
Falls increasing tried using sitters but not good use of productivity. Not all staff cued
in to answering others call lights.
2
Made it a challenge so staff would have some buy in to make the 100 day goal.
3
Made it to 34 days no falls when we had a fall that was due to defective equipment,
and call light not ringing to staff, came up with process to check all supplies and
equipment prior to placing patient into. Also developed a plan for a workgroup to
routinely check all equipment and that it is in working order.
4
result of this improvement
process
There will be guidelines based on
the Morse fall scale of 45 or
greater that the beds will be set
as follows.
Brake on, Bed plugged into nurse
call system, side rails up, bed in
low position, bed alert on and
programed to zone two, ibed on.
All alarms are programed into
every staffs phone and if the
alarm goes off everyone goes.
Increase in falls from July thru
September that doubled our
yearly fall total. Did not meet our
goal of no falls with injury and to
reduce falls my 50% from
previous years total.
1
What will be done differently as a
Continuing now into January day
Fall tree on the unit with leaves
placed with every day there is no
falls, if a fall occurs all the leaves
will come off.
Follow Up
1.
What are the next steps?
Bed audits to ensure all the above
criteria are met
No further falls for the 100 days
we set for out goal.
24
TOPIC: Medication Education
DATE:11/1/13
HOSPITAL: Calumet Medical Center
Aim Statement:
Lessons Learned
Measure
To improve and be consistent
with medication education
and documenting purpose
of med in patient copy of
med list at least by 50% in
90 days.
Manual audit of patient copy of med
list at discharge to reflect
purpose
HCAHPS: Understood the purpose
of medication
1)
Time consuming- needs to
be done prior to discharge
2)
Provider compliance is a
challenge
3)
Written info appreciated by
patients
4)
Pt education is easier and
consistent with medication
cheat sheet.
Test Cycles
Root Cause(s)?
1.
2.
Patient don’t always know
their meds and its purpose –
potentially impacting
compliance.
Pt education is inconsistent
and lacking ( purpose, side
effects and when best to
take)
1
2
Ask patient on admit if they know purpose
of meds – overwhelming majority doesn’t
know
RN to review medication purpose from
medical record – not always documented
on record
Follow Up
1.
Manual audit for medpurpose and reinforce
3
Med purpose to be completed on discharge
– time consuming and delayed discharge
2.
Work with providers to
improve documentation
4
Started documenting purpose of meds on
admit and during stay and working with
providers as admission med-rec is being
completed to include purpose of each med.
3.
Encourage use of mededuc cheat sheet for
consistency, validate on
rounding with patient
5
25
TOPIC: Discharge teaching
DATE: 1/7/14
HOSPITAL:
Hayward Area Memorial Hospital
Aim Statement:
120
1.
What was your 90 day aim?
Increase patient satisfaction
with discharge education as
evidenced by an increase in
HCHAPS scores by
12/31/13.flkasjflkdjflkjsdfkljf
Lessons Learned
Measure
100
100
87.5
91.7
83.3
1.
100 100
80
60
staff
40
SYMPTOMS
A randomized audit of charts
was done for the month of
November and December to
audit for documentation of
“teach back” on discharge. This
audit found nursing used teach
back in 38% of the randomized
chart review in November and
39% in December.
20
0
1
What is the cause of the problem?
Nursing was instructing the
patient on discharge, in
regards to signs and
symptoms and medications.
However, the patient was not
always understanding what
was being taught.
Therefore, when the patients
returned home, the HCAHPS
scores reflected that the
patient did not feel that
teaching was done to
prepare them for self care at
home.
3
Test Cycles
Root Cause(s)?
1.
2
1
Nursing was educated on teach back at a staff meeting
with a power point presentation. This was also emailed to
those that did not attend. Examples of teach back
techniques were given.
2
Changes were made to the EMR, with the teach back
method added for nursing to document against.
3
Evidenced by increase in HCAHPS scores related to the
questions; “Staff talk about help when you left?” and
“Information regarding symptoms/problems to look for?”
(See above graph) For the months of October,
November, and December.
4
Plan to directly observe staff while discharging a patient
and performing teaching using the teach back method.
5
Have staff role play “teach back” techniques.
What will be done differently as
a result of this improvement
process?
Nursing will be re-educated on
the teach back method and the
importance.
Follow Up
1.
What are the next steps?
To continue to audit the use of
teach back and trend HCAHPS
scores related to patient
understanding of medications and
discharge instructions.
Re-educate Nursing on “teach
back” method.
26
Summarizing
Lessons Learned from
the 90 Day Challenge
27
Upcoming Topics
Patient Safety
 Reducing Hospital Acquired Conditions
 How to do good follow-up calls to prevent
readmissions
Leadership
 How staff can become leaders
 Leadership rounding
Spreading TCAB – A joint webinar with Cohort 3
 Staff participation and feedback with TCAB
 Engagement of more staff in TCAB
 TCAB to other units
Feb
Mar
April
28
Keep the data flowing….
We will be wrapping up the data collection
with the March 30th due date.
We really want a complete data set so that we
can accurately reflect the improvement you
all have worked for.
 You can always check your current data on
the Quality Center data portal
29