Hospital Story - Registration123 · 2017-12-27 · Hospital Story Susan Bukunt, RN, MPA, CPHQ,...
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Hospital Story Susan Bukunt, RN, MPA, CPHQ, Senior Director of Clinical Quality & Patient Safety El Camino Hospital Mountain View, California
Transcript of Hospital Story - Registration123 · 2017-12-27 · Hospital Story Susan Bukunt, RN, MPA, CPHQ,...
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 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,
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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?
