Cohort 2 Coaching Call

March 12 2014Denise Flook

Cohort 2 Lead

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Share your good work!!!

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Sense of Urgency

Some is not a number;

soon is not a time.Don Berwick – 100Klives Campaign

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The Cohort ChallengeMarch to the Goal – Keeping the Beat

– Topics CAUTI and Falls with Injury– Rapid Cycle Improvement– Participation guidelines– Baseline Data

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Best Practices: CAUTI• Insert catheters only for appropriate indications using evidence based criteria including in

the OR and ED. • Daily assessment of catheter necessity and meeting criteria included in bedside report • Leave catheters in place only as long as needed. Use nurse driven protocols for catheter

removal • Facilitation of nurse/patient/family communication during report, rounding and interactions• Increase communication with nurse and physicians related to catheter continuation • Automatic removal orders after surgery • Ensure that only properly trained persons insert and maintain catheters. Perform staff

competency assessment related to urinary catheter insertion and maintenance • Insert catheters using aseptic technique and sterile equipment (acute care setting)• Maintain a closed drainage system• Maintain unobstructed urine flow• Perform proper hand hygiene and use Standard (or appropriate isolation) Precautions

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Falls with Injury: Definition Clarification

Clarification NDNQI Falls definitionInjury Level        When the initial fall report is written by the nursing staff, the extent of injury may not yet be known. Hospitals have 24 hours to determine the injury level, e.g., when you are awaiting diagnostic test results or consultation reports.  This is a required data element and you should report Falls with Injury through NOVI monthly based on the following guidelines: • None—patient had no injuries (no signs or symptoms) resulting from the fall; if an x-ray, CT scan or other post fall

evaluation results in a finding of no injury • Minor—resulted in application of a dressing, ice, cleaning of a wound, limb elevation, topical medication, pain,

bruise or abrasion • Moderate—resulted in suturing, application of steri-strips/skin glue, splinting, or muscle/joint strain • Major—resulted in surgery, casting, traction, required consultation for neurological (basilar skull fracture, small

subdural hematoma) or internal injury (rib fracture, small liver laceration) or patients with any type of fracture regardless of treatment or patients who have coagulopathy who receive blood products as a result of a fall

• Death—the patient died as a result of injuries sustained from the fall (not from physiologic events causing the fall)  

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Team Innovations in Professional Practice Award2014

Recognizing Excellence in Improving Patient Safety and Quality  Purpose: To recognize front line staff teams who have improved safe patient care and reduced harm through innovation and operationalization of practices, processes and through collaboration with multidisciplinary teams.

Goal: To promote front line staff engagement and leadership in patient safety and quality improvements to move to zero harm through collaboration with multidisciplinary teams in a rapid cycle.

Eligibility: Multidisciplinary hospital teams, led by front line staff, who has achieved an innovation in process/practice improvement that has led to significant reduction in Safety Across the Board or increased engagement of patients/family in care.  

Application due: April 21, 2014 by noon

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Cohort Update

• One combined cohort meeting per month for Cohorts 2, 3 and 4 – Meet 3rd Wednesday of month from 11:45 am– 12:45 pm

• Next cohort meeting April 16• Regional meetings (tentative)

– May 1, 8:30 am – 12:30 pm, Atlanta (GAPP meeting 1 – 4 pm)– May 8, Macon

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Data Submission – March 15:

Hen data Submission web site:https://quality.gha.org/Home/HospitalEngagementNetwork/HENDataSubmission.aspx.

– INR– Falls with injury– Glycemic Control– Opioids NEW!!– EED if applicable– HAI (if not submitting into NHSN)

• CLABSI, CAUTI – ICU , Med/Surg• SSI: Colon, Abd.Hyst• Knee Prosthesis due April 3 (hip pro optional) • VAE (NHSN only)

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EVALUATION

Remember Complete the evaluation for today’s Cohort 2 Coaching Call!

Link posted on Agenda