Eliminate VAP Coaching Call

February 7, 2013

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Objectives

• Share Daily Rounding Data Collection Process Methods

• Introduce Process Mapping• Highlight Next Steps

Group Discussion• When PEEP and Fi02 are measured

– Who documents it?– Where is it documented?

• For other process measures, e.g., HOB => 30 degrees, use of oral care, etc.– Who documents it?– Where is it documented?

• Who enters the data into the Patient Safety and Quality portal?• How do you manage coverage of these activities on off-shifts,

weekends, holidays and vacations?• How do you know if your process is working?• Who is responsible for training the data collectors?

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Process Mapping

Process Map• Process maps (also known as process diagrams or

flowcharts) allow teams to– Visualize a process– Identify the actual flow or sequence of events in a

process– Identify problem areas and unnecessary steps– Come to agreement on the steps of the process– Examine which activities may impact the process

performance– Compare and contrast actual versus ideal flow to identify

improvement opportunities and maximize efficiency

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Creating a Process Map

1. Determine the boundaries of the process– Clearly define where the

process starts (input) and ends (final output)

2. Determine the steps in the process– Brainstorm a list of all major activities, inputs,

outputs, transfers, handovers and decisions from the beginning of the process to the end

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Creating a Process Map3. Sequence the steps– Arrange the steps in the order they are carried out. – Sequence what is, not what should be. – Don’t draw in the arrows yet. – HAVE FUN!

Consider using Post-It® Notes so you can move steps

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Creating a Process Map

4. Draw the process map– Label each step in a way

that is understandable to everyone.

– Document who carries out the step.

– Add arrows to show the direction of the flow of each step in the process.

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Creating a Process Map

5. Test the process map– Validate the map. – Follow the people who

carry out the process and adjust the map as needed to reflect the current process.

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Creating a Process Map6. Finalize the process map– Is this process being run the

way it should be?– Are people following the process

as charted?– Are there obvious complexities or redundancies that can

be reduced or eliminated?– How different is the current process from an ideal one?– Draw an ideal Flowchart. Compare the two (current

versus ideal) to identify discrepancies and opportunities for improvements.

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Considerations• Minimize the potential for staff burnout by

distributing responsibilities among many.• Identify which steps can be carried out

by non-clinical staff and delegate accordingly.

• Think about how can you tweak the environment (i.e., the systems) to better support the process and minimize the likelihood for “cutting corners.”

• How will you know if your process is working as designed?

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• Take our Pit Stop challenge!• Create a map or flowchart documenting your

current processes for daily rounding data collection – weekdays and weekends.

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You will be judged on:1. Submitting by March 8 to kwicker@mhaonline.org or fax 410-379-82392. Level of detail in the process map/flowchart - Include what, how, and who - Hand-drawn maps accepted!3. Identification of opportunities for improvement/problem areas - e.g., unnecessary steps, bottlenecks, lack of coverage, etc.4. Description for how the process will be modified to overcome problem areas

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Next Steps1. Daily Rounding Data Collection

– Continue to collect.– Submit data to Patient Safety and Quality portal

https://armstrongresearch.hopkinsmedicine.org/Default.aspx

2. VAE Collection– Continue to collect. – Submit January data into NHSN when module becomes available (expected mid

February)

3. Participate in Quarterly Interview4. Accessing the Social Networking Site

– Instructions available at: http://www.mhaonline.org/File%20Library/Quality/Eliminate%20Ventilator-Associated%20Pneumonia/Connecting-to-the-Social-Networking-Site.pdf

5. Hospital Survey on Patient Safety Culture (HSOPS)– Prepare to conduct survey.– If conducted in the last 12 months, results can be uploaded to the Patient Safety and

Quality portal

Next Webinar

• February 14 Content Call at 2:00 PM• Audio: 800-779-9891• Pass code: 4757941• Web link:

https://connect.johnshopkins.edu/cuspevap/

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Questions?

• Maryland Participants– Karol G. Wicker, MHS– Phone 410-540-5056– kwicker@mhaonline.org

• Pennsylvania Participants– Mary Catanzaro, RN BSMT CIC– Phone 717-756-3958– mcatanzaro@haponline.org