2. Cohort 1 Coaching Call March 5 2014 Facilitators: Lisa Carhuff Kathy McGowan Joyce Reid

3. Learn. Act. Improve. Spread. Keep the Drum Beat Going. WELCOME and Introductions 2

4. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 3 Sense of Urgency Some is not a number; soon is not a time. Don Berwick – 100Klives Campaign 3

5. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 4 Key Concepts Culture of Safety Promoted from the Top Ownership at Point of Care Engaging patients in redesign 4

6. Learn. Act. Improve. Spread. Keep the Drum Beat Going. Model for improvement 5

7. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 6 The Cohort Challenge March to the Goal – Keeping the Beat – Topics CAUTI and Falls without Injury – Rapid Cycle Improvement – Participation guidelines – Baseline Data 6

8. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 7 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

9. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 8 Sharing Best Practices: CAUTI Jane Chesser, RN, CIC Infection Control Director Memorial Hospital and Manor 8

10. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 9 Falls with Injury: Definition Clarification Clarification NDNQI Falls definition Injury 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) 9

11. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 10 Sharing Best Practices: Fall Prevention Selina Baskins, RN Quality Coordinator Northridge Medical Center

12. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 11 Northridge Medical Center 11

13. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 12 Sharing Best Practices: Fall Prevention Erica Fishell Sylvan Grove

14. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 13 Team Innovations in Professional Practice Award 2014 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 13

15. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 14 Data Submission – March 15: NOVI Survey – INR – Falls with injury – Glycemic Control – Opioids NEW!! – EED if applicable – Infection (if not submitting via NHSN) 14

16. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 15 EVALUATION Remember Complete the evaluation for today’s Cohort 1 Coaching Call! Link posted on Agenda 15