HAI Collaborative Meeting May 9 , 2012

HAI Collaborative MeetingMay 9, 2012

Denise Flook, RN, MPH, CIC HAI Collaborative Lead

Vice President, Infection Prevention/Staff Engagement

Learn. Act. Improve. Spread. Keep the Drum Beat Going.

Learning Objectives

• Identify keys to engaging all staff in Patient Safety.

• Discuss successful strategies to ensure proper line maintenance.

• Outline the steps to participate in the HAI Listserv.

• Identify the action steps your team should complete before the June meeting.


Net Forward Energy

Share a win or success from the last month


The PfP andGeorgia HEN Community of Practice

• Community of Practice for Partnership for Patients– Healthcare Communities

• Georgia HEN CoP• HAI group

– Ability to post and answer questions – Resources and links– Share knowledge!

http://www.healthcarecommunities.org/


Five Phases of Improvement

1. Project Identification2. Diagnostic3. Interventions4. Impact & Implementation5. Sustaining


Phase Three – Interventions: Tests of Change

1. Select the intervention(s)2. Use the selected method: – PDSA – LEAN/Six Sigma – Reliable systems process design

3. Implement the Test Process4. Measure the Process5. Improve the Process


Staff Engagement – A Continual Process

• Culture of safety, responsibility, accountability• Senior leadership/support• Tied to mission/vision/values of the hospital• Based on relationships – requires building• Connect to professional values• Responsibility for practice


Staff are empowered and engaged when:

• they see change happen• their concerns are affirmed• they develop a voice and can tell their story• they are supported by a unit culture that values speaking

up regarding patient safety• they work in a positive, healthful work environment

Nurses/Staff are empowered when they actually have power

On The Cusp - Stop BSI Website

http://www.onthecuspstophai.org/


Elements of A Healthful Work Environment

• Collaborative Practice Culture• Communication Rich Culture • A Culture of Accountability • Presence of Adequate Numbers of Qualified Employees • Presence of Expert, Competent, Credible, Visible Leadership• Shared Decision-Making at All Levels• Encouragement of Professional Practice & Continued

Growth/Development • Recognition of the Value and Contribution to Hospital Mission

* Adapted from Principles & Elements of A Healthful Practice/Work Environment, Nursing Organizations Alliance., 2004.


A Positive, Healthful Work Environment

• A culture focused on caring – focused on patients and employees

• Sincere care and concern for person – make each infection personal

• Equitable but flexible treatment • Coach poor performers• Support for speaking up • Do not allow disruptive, bullying behavior by anyone

(physicians, peers, shifts, professions, gender, generational, etc.)

• Safe work equipment and resources, ergonomics• Employee health practices


Shared Accountability

• Clearly delineate how initiatives relate to hospital vision, mission, values and everyone's importance

• Effective, timely education • Communicate specific expectations and hold everyone

accountable• Support for holding others accountable – peers and

physicians• Feedback, especially positive, not just numbers• Fairness


Effective Engagement Tools

• Connect staff to the “Why” and sense of professional commitment • Build relationships

– Trust– Communication– Clear Expectations– Staff Level Involvement – Accountability– Feedback– Shared Learning– Celebration

• Clear policies that allow for accountability but flexibility– Just Culture– Performance evaluation based on outcomes, targets

• Provide reward and recognition based on employee preference• Provide a safe, healthy work environment


What the Grassroots Say

• Relationships with others is key• Visibility of C’s and managers • Accessibility of above• Authenticity and sincerity • Recognition• Courtesy, respect


There is a lot of “Noise”

• Choose a strategic approach and stick to it • Orderly introduce number of changes, new

programs • Use evidence based strategies


Strategies that Promote Staff Involvement

• Frontline staff are an integral part of the unit team– Those who work perform the processes everyday are the best people to identify where

there are opportunities to improve and how to improve

• Embrace diversity, including generational • Allow the nurse/staff to take responsibility for identifying problems and

give them a forum and strategy to solve them– CUSP team– RCA– Structured daily safety huddles

• Teams should meet monthly – Assess progress– Recommend improvements– Celebrate

www.onthecuspstophai.org.


A Voice That Is Heard, Valued Is Key

• Participation in decision making that affects them/practice

• Response to ideas• Response to concerns


Want An Engaged Staff?

Ask ThemListen to Them

Show Them


HAI Measures

• Process Data Measurement– Is the process you implemented effective?

• Small sample – 10 patient/charts– Was compliance to the bundle/checklist 100%– Numerator – number meeting compliance – Denominator – number of charts reviewed

• Process Data submission due May 26 • If you have not implemented your

bundle/checklist/process yet do survey, put N/A for each and put the reason at end

• Ask 5 people what the process is


Data Submission Due Dates

• Baseline Data due May 2 (Baseline Outcomes Data only) • April Process Data due May 26• May Process Measure Data by June 20• June Process Measure Data by July 18• July Process Measure Data by August 15• August Process Measure Data by September 19• September Process Measure Data by October 17• October Process Measures Data by November 21• November Process Measures by December 19• Outcomes Data should be submitted into NHSN by the

21st of the month following the collection month.


Next Steps

• Meet with team, review data or progress in work• Meet with unit staff to discuss target, why, process and aim • Assess process and need for any changes• Retest process change • Submit Process Measure for targeted HAI by May 26• Join the Georgia HEN Community of Practice and

participate in the HAI group• Complete meeting evaluation by May 15– Ask for assistance if needed including an onsite coaching

visit


Central Line Maintenance

• Develop a process • Test the process• Change if needed • When ready, policy/procedure • Educate/competency assessment

– Include why important first• Observe/monitor if being done correctly• Just in time training if found not correct


Considerations

• Ask every day if device still necessary according to criteria/patient need

• Remove if not needed• Access requirements• Who should be responsible?• Frequency/procedure of dressing/tubing change

or device care• Site cleansing• Dressing type/change procedure


Resources

• Sample policies for various central linesOn The CUSP Stop HAI

• CDC Guidelines CDC Guidelines • Infusion Nurses Society Standards of Practice

INS1

http://www.onthecuspstophai.org/

http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5110a1.htm

http://www.ins1.org/


Open Mic

• Ask questions• Ask for special assistance• Make offers and requests


CONTACT INFORMATION

Denise [email protected].

770-249-4518

mailto:[email protected]

HAI Collaborative Meeting May 9 , 2012

Documents

Transcript of HAI Collaborative Meeting May 9 , 2012