Post on 18-Feb-2016
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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.
Learn. Act. Improve. Spread. Keep the Drum Beat Going.
Net Forward Energy
Share a win or success from the last month
Learn. Act. Improve. Spread. Keep the Drum Beat Going.
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!
Learn. Act. Improve. Spread. Keep the Drum Beat Going.
Five Phases of Improvement
1. Project Identification2. Diagnostic3. Interventions4. Impact & Implementation5. Sustaining
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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
Learn. Act. Improve. Spread. Keep the Drum Beat Going.
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
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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
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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.
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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
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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
Learn. Act. Improve. Spread. Keep the Drum Beat Going.
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
Learn. Act. Improve. Spread. Keep the Drum Beat Going.
What the Grassroots Say
• Relationships with others is key• Visibility of C’s and managers • Accessibility of above• Authenticity and sincerity • Recognition• Courtesy, respect
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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
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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.
Learn. Act. Improve. Spread. Keep the Drum Beat Going.
A Voice That Is Heard, Valued Is Key
• Participation in decision making that affects them/practice
• Response to ideas• Response to concerns
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Want An Engaged Staff?
Ask ThemListen to Them
Show Them
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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
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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.
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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
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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
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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
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Resources
• Sample policies for various central linesOn The CUSP Stop HAI
• CDC Guidelines CDC Guidelines • Infusion Nurses Society Standards of Practice
INS1
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Open Mic
• Ask questions• Ask for special assistance• Make offers and requests
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CONTACT INFORMATION
Denise Flookdflook@gha.org.
770-249-4518