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H E A L T H I E R P O P U L A T I O N S b e t t e r h e a l t h c a r e VALUE MHA Immersion Pilot Projects: A COMPENDIUM
Transcript of MHA Immersion Pilot Projects: A COMPENDIUMweb.mhanet.com/SQI/Immersion/2016 Compendium_for...
HEALTHIER
PO
PULA
TIONS
better h
ealth
care
VALU
E
MH
A Im
mer
sion
Pilo
t Pro
ject
s:A
CO
MPE
ND
IUM
1
Seps
is I
mm
ersi
on P
roje
ctD
r. M
ark
Gal
ant
(Hos
pita
list)
, Car
ol L
ewis
(Q
ualit
y M
anag
emen
t),
Jenn
ifer
Schm
ehl R
N (
Med
ical
-Sur
gica
l Uni
t M
anag
er),
Jen
nife
r Kl
inks
ick
RN
(CCU
/Tel
e U
nit
Man
ager
), M
ark
Jone
s RP
h, C
arm
en M
atte
r RN
(In
fect
ion
Cont
rol),
Reb
ecca
Tar
ver
RN (
CNO
), C
aris
sa M
argr
ave
RN (
Educ
atio
n Co
ordi
nato
r), K
elly
Phi
llips
(ED
/EM
S D
irect
or)
PRO
JECT
FO
CUS
•To
def
ine
and
outli
ne t
he p
roto
cols
for
BCM
H
staf
f to
iden
tify
and
trea
t pa
tient
s w
ho a
re a
t ris
k of
sev
ere
seps
is/s
eptic
sho
ck.
•To
impl
emen
t di
agno
stic
scr
eeni
ng c
riter
ia f
or
adul
t an
d pe
diat
ric s
epsi
s pa
tient
s fo
r th
e Em
erge
ncy,
Am
bula
nce,
Med
/Sur
g, C
CU a
nd
Tele
met
ry D
epar
tmen
ts.
INIT
IAL
PRO
JECT
BAR
RIER
S ID
ENTI
FIED
•M
anua
l abs
trac
tion
from
ele
ctro
nic
heal
th
reco
rd.
•Ed
ucat
ion
not
hard
-wire
d in
all
depa
rtm
ents
.•
Buy
in a
nd im
plem
enta
tion
by s
taff
.•
No
scre
enin
g to
ol a
vaila
ble.
•La
bora
tory
tim
e cr
itica
l dra
ws
obta
ined
.•
No
seps
is p
roto
col o
r gu
idel
ine
in p
lace
.
KEY
SOLU
TIO
NS
IMPL
EMEN
TED
•Se
psis
scr
eeni
ng t
ool i
mpl
emen
ted
in E
D a
nd in
ac
ute
care
. St
aff
used
the
too
l to
asse
ss a
ll pa
tient
s.•
Dev
elop
ed a
sep
sis
guid
elin
e, o
rder
set
s, a
nd
prot
ocol
for
adu
lt an
d pe
diat
ric p
atie
nts.
•Se
psis
rap
id r
espo
nse
kit
crea
ted
and
plac
ed in
ED
.•
Entir
e pa
tient
car
e st
aff
com
plet
ed o
nlin
e se
psis
ed
ucat
ion
with
con
tent
qui
z.•
Vide
use
d to
eng
age
staf
f: “
Seps
y Ba
ck”
by
Kern
Med
ical
Cen
ter.
ht
tps:
//yo
utu.
be/2
WPn
P1YB
CD8
•Ca
re p
lan
deve
lope
d fo
r “A
t Ri
sk fo
r Se
psis
” an
d “S
ever
e Se
psis
”.
KEY
LESS
ON
S LE
ARN
ED
•W
e w
ere
not
accu
rate
ly id
entif
ying
sep
sis
patie
nts.
•Th
e ph
ysic
ian’
s di
agno
sis
did
not
alw
ays
mat
ch
seve
re s
epsi
s cr
iteria
.•
Ther
e w
ere
mor
e pa
tient
s pr
esen
ting
with
se
vere
sep
sis
than
we
orig
inal
ly e
xpec
ted.
•Ch
ange
s w
ere
need
ed t
o re
cogn
ize
and
trea
t se
vere
sep
sis
patie
nts.
•Th
e sc
reen
ing
tool
com
plet
ed b
y th
e st
aff
flagg
ed p
atie
nts
at r
isk
for
seps
is/S
IRS
and
in
turn
not
ified
the
phy
sici
an t
o ex
amin
e th
e pa
tient
for
diag
nosi
s.•
A le
sson
lear
ned
durin
g th
e pr
ojec
t w
as t
he
need
for
con
tinuo
us r
e-ed
ucat
ion
pert
aini
ng t
o se
psis
/SIR
S.•
SIRS
crit
eria
alo
ne is
not
a s
tron
g in
dica
tor
of
seps
is.
RESU
LTS/
RETU
RN O
N I
NVE
STM
ENT
•W
e w
ere
unab
le t
o ca
lcul
ate
savi
ngs
due
to o
ur
curr
ent
reve
nue
finan
cial
sys
tem
.•
We
wer
e ab
le t
o de
crea
se o
ur le
ngth
of
stay
.
RESU
LTS
TEAM
ACC
OM
PLIS
HM
ENTS
PERC
ENT
OF
PRO
JECT
QU
ARTE
RLY
TASK
S CO
MPL
ETED
•Fi
rst
Qua
rter
Tas
ks =
100
%•
Seco
nd Q
uart
er T
asks
=
100%
•Th
ird Q
uart
er T
asks
= 8
3%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Nov
-15
Dec
-15
Jan-
16Fe
b-16
Mar
-16
Apr-
16M
ay-1
6Ju
n-16
Nov
-15
Dec
-15
Jan-
16Fe
b-16
Mar
-16
Apr-
16M
ay-1
6Ju
n-16
Jul-1
6Bu
ndle
Ini
tiatio
n10
0%10
0%10
0%10
0%66
%40
%10
0%89
%83
%La
ctat
e le
vel w
ithin
3 h
ours
100%
100%
100%
100%
100%
100%
100%
100%
100%
Bloo
d cu
lture
s pr
ior
to a
n an
tibio
tic10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%
Seps
is/S
IRS
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Nov
-15
Dec
-15
Jan-
16Fe
b-16
Mar
-16
Apr
-16
May
-16
Jun-
16Ju
l-16
Nov
-15
Dec
-15
Jan-
16Fe
b-16
Mar
-16
Apr-
16M
ay-1
6Ju
n-16
Jul-1
6An
tibio
tic g
iven
w/
in 3
hrs
100%
100%
100%
100%
66%
100%
83%
100%
86%
Rece
ived
IV
fluid
s w
/in 3
hrs
100%
100%
100%
100%
100%
100%
100%
100%
100%
Repe
at la
ctat
e at
6 h
ours
100%
100%
100%
100%
100%
100%
50%
0%67
%
•Co
nclu
sion
1:
Im
prov
emen
t in
iden
tifyi
ng
early
sep
sis/
SIRS
pat
ient
s.•
Conc
lusi
on 2
: I
mpr
oved
col
labo
ratio
n be
twee
n de
part
men
ts in
iden
tifyi
ng a
nd
prov
idin
g co
ntin
uity
of
care
. con
tinui
ty o
f ca
re.
•Co
nclu
sion
3:
Pro
toco
ls a
nd o
rder
set
s in
itiat
ed a
nd s
ucce
ssfu
lly u
tiliz
ed.
2
Imm
ersi
on P
ilot P
roje
ct: S
epsi
s
KEY
SOLU
TION
S IM
PLEM
ENTE
D
Esta
blis
hed
mul
tidis
cipl
inar
y co
mm
ittee
and
mon
thly
m
eetin
gs
Re
vise
d ED
tria
ge s
cree
ning
too
l to
incl
ude
all a
dults
(p
ositi
ve s
cree
ns a
re c
olor
cod
ed f
or n
ursi
ng s
taff
and
ph
ysic
ians
in E
MR)
Es
tabl
ishe
d cr
itica
l lab
val
ue f
or la
ctat
e >
4m
mol
/L
Im
plem
ente
d “c
ode
seps
is”
in E
D
IDEN
TIFI
ED B
ARRI
ERS
TO P
ROJE
CT
SUCC
ESS
BIG
ACCO
MPL
ISH
MEN
TS
•Br
ingi
ng a
ll th
e ne
cess
ary
disc
iplin
es to
geth
er to
wor
k to
war
ds th
e se
psis
rela
ted
goal
s
•Im
plem
enta
tion
of in
patie
nt se
psis
scre
enin
g
•Co
llabo
ratio
n w
ith E
MR
vend
or to
impr
ove
docu
men
tatio
n fo
r el
emen
ts o
f cor
e m
easu
res
•Co
llabo
ratio
n w
ith E
MS
TASK
S %
COM
PLET
ION
•fir
st q
uart
er ta
sk c
ompl
etio
n 10
0%•
seco
nd q
uart
er ta
sk c
ompl
etio
n 90
%•
third
qua
rter
task
com
plet
ion
100%
Char
ts
Pict
ure
RETU
RN O
N IN
VEST
MEN
T
BIGG
EST
LESS
ONS
LEAR
NED
Serie
s 1, 4
.5
Serie
s 2, 2
.8
Serie
s 3, 5
0123456
Cate
gory
1Ca
tego
ry 2
Cate
gory
3Ca
tego
ry 4
Axis Title
Char
t Titl
e
TEAM
MEM
BERS
•A
mul
tidisc
iplin
ary
team
is c
ritic
al
•Al
low
ade
quat
e tim
e fo
r sta
ff &
phy
sicia
n ed
ucat
ion
–pr
ovid
e on
goin
g re
min
ders
•Ef
fort
s hav
e to
be
abou
t im
prov
ing
patie
nt c
are
not j
ust
mee
ting
core
mea
sure
s
•U
tilize
EM
R to
full
adva
ntag
e fo
r sep
sis re
late
d no
tific
atio
ns a
nd re
quire
d do
cum
enta
tion
• ED
tria
ge sc
reen
ing
tool
was
lim
ited
to 6
chi
ef c
ompl
aint
s an
d di
d no
t inc
lude
all
adul
t pat
ient
s
•Lac
k of
supp
ort f
rom
med
ical
staf
f ser
ving
in th
e at
tend
ing
role
•Sep
sis c
omm
ittee
did
not
hav
e an
adm
inist
rativ
e ch
ampi
on
•Sep
sis c
omm
ittee
was
not
mul
tidisc
iplin
ary
Impl
emen
tatio
n of
the
“cod
e se
psis”
in th
e ED
has
incr
ease
d re
spon
se ti
me
for t
he m
easu
res i
n th
e 3º
bun
dle
Impl
emen
tatio
n of
the
inpa
tient
seps
is sc
reen
allo
ws f
or
early
iden
tific
atio
n of
cha
nges
in p
atie
nt c
ondi
tion
40%
45%
50%
55%
60%
65%
70%
75%
80%
85%
90%
95%
100%
Jan,
2016
Feb,
2016
Mar
,20
16Ap
r,20
16M
ay 3
1,20
16Ju
n 30
,20
16Ju
l,20
16Au
g,20
16
Precent compliance
Repo
rtin
g Ti
mef
ram
e
Initi
al L
acta
te
0%20%
40%
60%
80%
100%
120%
Jan,
2016
Feb,
2016
Mar
,20
16Ap
r,20
16M
ay 3
1,20
16Ju
n 30
,20
16Ju
l,20
16Au
g,20
16
Precent compliance
Repo
rtin
g Ti
mef
ram
e
IV F
luid
s
0%20%
40%
60%
80%
100%
Jan,
2016
Feb,
2016
Mar
,20
16Ap
r,20
16M
ay 3
1,20
16Ju
n 30
,20
16Ju
l,20
16Au
g,20
16
Percent compliance
Repo
rtin
g Ti
mef
ram
e
Broa
d Sp
ectr
um A
ntib
iotic
s
Com
mitt
ee M
embe
rs: V
P-N
ursin
g, E
D N
urse
Dire
ctor
, Inp
atie
nt
Nur
se M
anag
ers,
ED
Med
ical
Dire
ctor
, Hos
pita
lists
, Pha
rmac
y, La
b, IT
, RT,
Edu
catio
n, E
MS,
Qua
lity
3
Imm
ersi
on P
ilot P
roje
ct: S
epsi
s
KEY
SOLU
TION
S IM
PLEM
ENTE
D•
Seps
is Co
mm
ittee
form
ed w
ith k
ey m
embe
rs o
f hos
pita
l sta
ff.•
Seps
is Q
uiz f
or N
ursin
g st
aff b
efor
e in
itiat
ion
of ta
ctic
s, S
epsis
Qui
z fol
low
ing
HEN
2.0
to re
test
kn
owle
dge.
•Ed
ucat
ion
to N
ursin
g St
aff a
nd P
rovi
ders
rega
rdin
g bu
ndle
met
hods
.•
Initi
atio
n of
Adu
lt Se
psis
Man
agem
ent P
athw
ay F
orm
and
edu
catio
n pr
ovid
ed to
pro
vide
rs a
nd n
ursin
g st
aff.
•Pr
ovid
er a
nd N
ursin
g Se
psis
Cham
pion
s.•
Educ
atio
n an
d Lu
nche
on fo
r Clin
ic N
urse
s.•
Min
i-Bun
dle
shee
t che
ats c
reat
ed fo
r Nur
sing
badg
es.
•Se
psis
Trac
er in
itiat
ed.
•Se
psis
Ord
er S
et in
itiat
ion.
•Pr
ovid
er E
duca
tion
lunc
heon
to d
iscus
s pos
sible
impl
emen
tatio
n of
Sev
ere
Seps
is an
d Se
ptic
Sho
ck A
lert
s th
roug
h EM
R.•
Wor
ld S
epsis
Day
fact
shee
t in
Empl
oyee
New
slett
er fo
r Sep
tem
ber.
Cak
e se
rved
to ra
ise a
war
enes
s
IDEN
TIFI
ED B
ARRI
ERS
TO P
ROJE
CT
SUCC
ESS
BIGG
EST
ACCO
MPL
ISH
MEN
T •
Staf
f ed
ucat
ion
on si
gns a
nd sy
mpt
oms a
nd e
arly
reco
gniti
on o
f se
psis.
•Ra
ising
aw
aren
ess r
egar
ding
bet
ter p
atie
nt o
utco
mes
from
ear
ly
reco
gniti
on.
•Re
cogn
izing
the
impo
rtan
ce o
f tea
m w
ork
invo
lvin
g pr
ovid
er
clin
ics,
em
erge
ncy
room
, inp
atie
nt n
ursin
g, a
nd o
ther
clin
ical
de
part
men
ts.
COST
SAV
INGS
•
We
do n
ot h
ave
a m
easu
reab
le im
prov
emen
t in
cost
savi
ngs a
t th
is tim
e du
e to
min
imal
Dia
gnos
is of
seps
is. W
e fo
rese
e co
st
savi
ngs i
n th
e fu
ture
as w
e in
crea
se o
ur p
atie
nt se
rvic
es.
BIGG
EST
LESS
ONS
LEAR
NED
TEAM
MEM
BERS
•Th
e im
port
ance
of e
ach
indi
vidu
al ro
le in
ear
ly re
cogn
ition
of s
epsis
.
•Ke
epin
g th
e in
form
atio
n ea
sily
acce
ssib
le fo
r sta
ff.
•Th
e im
port
ance
of v
isual
pro
mpt
s use
d to
iden
tify
signs
and
sym
ptom
s.
•In
itiat
ion
of th
is co
mm
ittee
was
my
first
task
as a
new
em
ploy
ee h
ere
at C
CMH.
•I l
earn
ed th
at so
met
imes
you
can
hav
e to
o m
any
indi
vidu
als o
n a
com
mitt
ee.
•Fo
llow
- thr
ough
and
ens
urin
g th
e w
heel
s kee
p on
turn
ing
is ke
y!
02468101214161820
Dece
mbe
rJa
nuar
yFe
brua
ryM
arch
April
May
June
July
Augu
st
Adul
t Sep
sis P
athw
ay F
orm
Initi
atio
n VS
. SIR
S Al
ert E
MR
Dece
mbe
r 201
5-Au
gust
201
6
# fo
rms i
nitia
ted
SIRS
ALE
RT E
MR
Eric
Witt
R.P
h.Ta
nya
Land
FN
PHe
athe
r Van
deve
nter
RN
Min
dy K
elly
RN
Cind
y Gi
lman
RN
Tam
my
Craw
ford
LPN
Barb
ara
Smith
RN
Nic
ole
Fern
ande
zDa
niel
le E
lliot
t C.N
.A.
Kayl
a M
artin
LPN
Dr. A
ndy
Horin
e Sa
man
tha
Low
e RN
•Ce
lebr
atin
g ou
r win
s•
Prov
ider
and
Adm
inist
rativ
e Su
ppor
t•
Enga
ged
staf
f•
Dr. H
orin
e an
d Ta
nya
Land
FN
P fo
r rep
rese
ntin
g pr
ovid
ers o
n th
e Se
psis
Com
mitt
ee.
•Th
e ho
spita
l pro
vidi
ng u
s with
the
supp
ort a
nd e
quip
men
t ne
eded
to st
op se
psis
and
save
live
s.
WE
OWE
OUR
SUCC
ESS
TOO…
….
0%
100%
33%
0
50%
0
50%
0
100%
100%
00
0.51
1.52
2.53
3.5
Oct
ober
Nov
embe
rDe
cem
ber
Janu
ary
Febr
uary
Mar
chAp
rilM
ayJu
neJu
lyAu
gust
Seps
is Co
re M
easu
re C
ompl
ianc
e O
ctob
er 2
015-
Augu
st 2
016
# Pa
tient
s Qua
lifyi
ng fo
r Sep
sis C
ore
Mea
sure
% C
ompl
ianc
e
4
“SEP
SIS
ALE
RT”
: O
verc
omin
g Se
psis
Cha
lleng
esD
r. P
rest
on H
ower
ton
-ER
, Erik
Roe
hrs
–Ph
arm
acy,
Gin
a G
lisso
n -
QAP
I Co
ordi
nato
r, H
eath
er M
cRey
nold
s -
Clin
ical
IT,
Ja
na K
enne
dy –
Resp
irato
ry, A
nnet
te M
iles
–LA
B, J
ill D
eWee
se –
Infe
ctio
n Pr
even
tioni
st, M
egan
Liv
engo
od –
ICU
, As
hley
Pitt
man
–M
edSu
rg, K
atin
a La
xson
–ER
, Deb
bie
Smith
–W
C, A
ngel
a Ig
o -
Exec
utiv
e
PRO
JECT
FO
CUS
Seps
is is
one
of
the
top
10 m
ost
com
mon
prin
cipl
e ca
uses
for
hos
pita
lizat
ions
and
the
thi
rd le
adin
g ca
use
of d
eath
in t
he U
.S. a
ccor
ding
to
the
CDC.
Ear
ly
iden
tific
atio
n an
d ea
rly t
reat
men
t ar
e ke
y to
sur
vivi
ng
seps
is.
The
Imm
ersi
on P
roje
ct a
llow
ed F
itzgi
bbon
to
build
upo
n ou
r re
cent
impl
emen
tatio
n of
a s
epsi
s sc
reen
ing
tool
in o
ur E
mer
genc
y Ro
om a
nd f
ocus
ef
fort
s to
dev
elop
ing
best
pra
ctic
e w
orkf
low
s th
roug
hout
the
org
aniz
atio
n.
Our
eff
orts
incl
uded
ex
pand
ing
rout
ine
seps
is s
cree
ning
to
all h
ospi
taliz
ed
patie
nts
as w
ell a
s in
itiat
ing
early
res
usci
tatio
n ef
fort
s w
ith t
he b
undl
es.
INIT
IAL
PRO
JECT
BAR
RIER
S ID
ENTI
FIED
•O
verc
omin
g th
e se
psis
ste
reot
ype,
“Th
ey d
on’t
look
se
ptic
” &
“fa
lse
posi
tive
scre
ens”
•Id
entif
y em
ergi
ng s
epsi
s sy
mpt
oms
with
cha
nges
in
patie
nt c
ondi
tion
once
hos
pita
lized
•Ph
ysic
ian
buy-
in f
or b
undl
es:
•O
btai
ning
lact
ate
leve
ls•
Impl
emen
ting
fluid
bol
us 3
0mL/
kg
•D
evel
opin
g a
mut
ually
agr
eed
upon
wor
kflo
w f
or
the
entir
e he
alth
care
tea
m
KEY
SOLU
TIO
NS
IMPL
EMEN
TED
•Se
psis
Scr
eeni
ng T
ool h
ardw
ired
on in
itial
pre
sent
atio
n an
d ev
ery
shift
for
ER
& b
edde
d un
its•
Ord
er s
ets
deve
lope
d in
the
Ele
ctro
nic
Hea
lth R
ecor
d fo
r ea
se o
f or
derin
g al
l ele
men
ts o
f th
e bu
ndle
s•
Incr
ease
d s e
psis
aw
aren
ess
thro
ugho
ut o
rgan
izat
ion
&
adop
tion
of k
ey p
hras
e “S
epsi
s Al
ert”
& p
oste
r co
ntes
t•
Mut
ually
agr
eed
upon
wor
kflo
w f
or t
he e
ntire
he
alth
care
tea
m r
elat
ed t
o id
entif
icat
ion
& t
reat
men
t (E
R, M
edSu
rg, I
CU, W
omen
’s C
ente
r)•
Bloo
d cu
lture
s no
w p
erfo
rmed
in-h
ouse
•
Dai
ly d
iscu
ssio
n at
Dis
char
ge P
lann
ing
Mee
ting
by R
x,
Infe
ctio
n Pr
even
tion
RN &
Hos
pita
list
with
foc
us o
n an
tibio
tic s
elec
tion,
cul
ture
res
ults
, & r
enal
fun
ctio
n
KEY
LESS
ON
S LE
ARN
ED•
Perc
eptio
n of
fal
se p
ositi
ve s
cree
ns d
ebun
ked
•Li
nk b
etw
een
clin
ical
pre
sent
atio
n an
d co
ding
de
finiti
on o
f Se
psis
/Sev
ere
Seps
is/S
eptic
Sho
ck•
Bloo
d Cu
lture
sen
t to
Ref
eren
ce L
ab a
ffec
ting
turn
-a-
roun
d tim
es a
nd le
ngth
of
stay
•
Staf
f to
und
erst
and
seps
is s
cree
ning
crit
eria
as
it re
late
s to
pat
ient
s un
derg
oing
che
mot
hera
py•
Prov
ider
s re
luct
ant
in u
sing
ord
er s
et, o
rder
ing
bund
les
“a
la c
arte
”
Qua
rter
1Q
uart
er 2
Qua
rter
3
Perc
ent
of P
roje
ct
Qua
rter
ly T
asks
Co
mpl
eted
10
0%*
100%
100%
* Le
arni
ngfr
om D
efec
t in
stea
d of
FM
EA
PD
SA’s
Seps
isKi
tSt
aff,
Patie
nt &
Fam
ily E
duca
tion
Reso
urce
sSe
psis
Pos
ter
Cont
est
–“Y
our
Role
in P
reve
ntio
n or
Tre
atm
ent
of S
epsi
s”Co
nfirm
ing
Scre
enin
g To
ol R
elia
bilit
y (F
alse
+ /
Fal
se -
)Bl
ood
Cultu
res
Perf
orm
ed I
n-ho
use
Colla
bora
tive
Focu
s on
Sep
sis
at D
aily
Dis
char
ge P
lann
ing
Mee
ting
Gra
nd P
rize
and
Runn
er U
p Se
psis
Pos
ter
Cont
est
Win
ners
RESU
LTS/
RETU
RN O
N I
NVE
STM
ENT
•Sh
orte
r le
ngth
of
stay
due
to
turn
-a-r
ound
tim
es f
or
bloo
d cu
lture
s &
gra
m s
tain
s •
Tim
ely
antib
iotic
cha
nges
bas
ed o
n cu
lture
res
ults
(A
ntib
iotic
Ste
war
dshi
p)•
Seps
is K
its -
Equi
pmen
t in
the
rig
ht p
lace
at
the
right
tim
e•
Redu
ced
bloo
d cu
lture
con
tam
inat
ion
rate
s:•
TRU
LY p
ositi
ve b
lood
cul
ture
s•
Righ
t an
tibio
tics
sele
cted
RESU
LTS
TEAM
ACC
OM
PLIS
HM
ENTS
•Ea
rly r
ecog
nitio
n &
inte
rven
tion
with
inpa
tient
s•
Har
dwire
d se
psis
scr
eeni
ng o
n ev
ery
patie
nt
pres
entin
g to
the
ER
and
rout
inel
y on
Med
Surg
, IC
U, W
omen
’s C
ente
r•
Impl
emen
ted
refle
x re
peat
lact
ate
leve
l ord
er•
Bloo
d cu
lture
s no
long
er a
sen
d ou
t te
st•
Expa
nded
ski
ll va
lidat
ion
for
bloo
d cu
lture
col
lect
ion
•Re
cogn
izin
g in
divi
dual
s w
ith Z
ero
Cont
amin
atio
ns
•Su
ppor
t An
tibio
tic S
tew
ards
hip
thro
ugh
Dai
ly
Dis
char
ge P
lann
ing
mee
tings
of
the
Mul
tidis
cipl
inar
y Te
am
5
MH
A Im
mer
sion
Pilo
t Pro
ject
: Sep
sis
[
KEY
SOLU
TION
S IM
PLEM
ENTE
D•
Early
reco
gniti
on p
aper
wor
kshe
ets
•El
ectr
onic
tria
ge a
sses
smen
t with
risk
scor
e•
Badg
e bu
ddie
s•
FIRS
T pa
nel i
n EM
R•
ED p
hysic
ian-
auth
ored
seps
is bu
ndle
-com
plia
nt o
rder
shee
t•
Use
of i
Stat
lact
ate
•O
n-de
man
d ed
ucat
ion
for P
hysic
ians
, Nur
ses &
Nur
se Te
chs i
nclu
ding
Gr
and
Roun
ds w
ith C
ME
& C
EU•
Wee
kly
deta
iled
feed
back
on
seps
is pe
rform
ance
for l
eade
rs•
ED p
olic
y fo
r ear
ly re
cogn
ition
& tr
eatm
ent r
ecom
men
datio
ns fo
r sep
sis
IDEN
TIFI
ED B
ARRI
ERS
TO P
ROJE
CT
SUCC
ESS
BIGG
EST
ACCO
MPL
ISH
MEN
T •
Staf
f abi
lity
to re
cogn
ize se
psis
earli
er in
its p
rogr
essio
n•
Impr
oved
3 h
our b
undl
e co
mpl
etio
n ra
te –
near
ly d
oubl
ed o
ur su
cces
s an
d de
crea
sed
our m
orta
litie
s•
Mon
th lo
ng se
psis
awar
enes
s act
ivity
in S
epte
mbe
r•
Mul
tidisc
iplin
ary
part
icip
atio
n, in
clud
ing
busin
ess
supp
ort s
taff
•Pr
izes w
ere
awar
ded!
TASK
S %
COM
PLET
ION
•46
0-be
d, 3
-hos
pita
l sys
tem
loca
ted
in so
uthw
est M
issou
ri•
Regi
onal
refe
rral
cen
ter
•30
0+ p
hysic
ians
•60
+ sp
ecia
lties
COST
SAV
INGS
BIGG
EST
LESS
ONS
LEAR
NED
TEAM
MEM
BERS
•FH
S m
orta
litie
s wer
e lo
wer
than
nat
iona
l ave
rage
•N
early
all
seps
is pa
tient
s hav
e pn
eum
onia
or a
n ur
inar
y tr
act i
nfec
tion
•Te
amw
ork
and
com
mun
icat
ion
are
criti
cal t
o su
cces
s•
Lack
of c
larit
y ar
ound
seps
is bu
ndle
ele
men
ts w
ith re
cent
ly re
leas
ed
defin
ition
of S
epsis
3•
Imm
ersio
n pr
ojec
t cou
pled
with
seps
is co
re m
easu
re ro
ll-ou
t cau
sed
conf
usio
n•
Tran
sitio
n fr
om E
D to
inpa
tient
uni
ts a
nd E
D bo
ardi
ng c
reat
es a
n op
port
unity
for m
issed
bun
dle
piec
es•
Seps
is sp
ecifi
c SB
AR
•Fu
ll se
psis
path
way
ord
er se
t und
erut
ilize
d be
caus
e of
leng
th•
Sing
le p
age
seps
is Co
re M
easu
re p
roto
col
•Co
de S
epsis
ale
rt n
ot w
ell r
ecei
ved
by p
rovi
ders
•Co
ntin
ued
refin
emen
t of w
ho sh
ould
resp
ond
•EM
R up
grad
e an
d ab
stra
ctio
n gu
idel
ine
chan
ges i
n Ju
ly c
ause
d so
me
diffi
culty
with
sust
aina
bilit
y•
Inte
rven
tions
are
ofte
n ap
prop
riate
and
com
plet
ed b
ut n
ot
docu
men
ted
adeq
uate
ly to
mee
t CM
S ab
stra
ctio
n re
quire
men
ts
•N
o po
licy/
prot
ocol
•O
utda
ted
orde
r set
s•
Know
ledg
e de
ficit
arou
nd se
psis
iden
tific
atio
n an
d ev
iden
ce-b
ased
trea
tmen
t•
Hybr
id n
atur
e of
EM
R•
Lim
itatio
ns o
f EM
R fu
nctio
nalit
y•
Com
petin
g pr
iorit
ies
•Gl
obal
diff
icul
ty w
ith c
hang
e
0.0%
5.0%
10.0
%
15.0
%
20.0
%
25.0
%
30.0
%
Seve
re se
psis
ra
w a
ll ca
use
mor
talit
ies
FHS’
ove
rall
cost
inde
x =
0.82
Oct
ober
201
5 –
July
201
6 di
scha
rges
Live
s sa
ved
8Ex
cess
cos
t pe
r m
orta
lity*
$16,
304
ROI
To-D
ate
$130
,432
6
Libe
rty
Hos
pita
l: E
arly
Rec
ogni
tion
an
d In
terv
enti
on o
f Sep
sis
KEY
SOLU
TION
S IM
PLEM
ENTE
D•
Had
phys
icia
n ch
ampi
ons r
each
out
to p
rofe
ssio
nal g
roup
s with
co
ncer
ns a
nd sh
are
thei
r lea
rnin
g•
Upd
ated
Sep
sis a
sses
smen
t too
l and
re-e
duca
ted
all s
taff
•U
pdat
ed se
psis
orde
r set
with
new
reco
mm
enda
tions
and
re-
educ
ated
all
nurs
ing/
med
ical
staf
f•
Upd
ated
ACE
Nur
se ro
le w
ith S
epsis
and
med
ical
staf
f app
rova
l to
initi
ate
Seps
is O
rder
set
•De
velo
ped
Seps
is Ch
ampi
ons
•U
pdat
ed S
epsis
Bro
chur
e w
ith c
urre
nt re
com
men
datio
ns.
•Cr
eate
d ch
artin
g tip
s ref
eren
ce sh
eet f
or st
aff.
•U
pdat
ed A
CE te
am o
n se
psis
chan
ges a
nd h
ave
them
hel
p w
ith
real
tim
e au
dits
for s
epsis
cha
nges
and
cor
e m
easu
re
docu
men
tatio
n co
mpl
etio
n•
Seps
is ca
ses r
evie
wed
by
Med
ical
Sta
ff in
thei
r Qua
lity
Perf
orm
ance
Com
mitt
ee w
ith fo
llow
up
for i
mpr
oved
pe
rfor
man
ce.
•Se
psis
educ
atio
n of
med
ical
staf
f com
mitt
ees b
y m
edic
al st
aff
cham
pion
s.
IDEN
TIFI
ED B
ARRI
ERS
TO P
ROJE
CT
SUCC
ESS
BIGG
EST
ACCO
MPL
ISH
MEN
T •
Decr
ease
d m
orta
lity
•In
crea
sed
awar
enes
s and
a c
omm
itmen
t fro
m th
e en
tire
heal
thca
re te
am•
Impr
oved
com
mun
icat
ions
am
ongs
t the
team
•Im
prov
ed c
onsis
tenc
y of
med
ical
man
agem
ent
•Im
prov
ed d
ocum
enta
tion.
KEY
LESS
ONS
LEAR
NED
•Pe
rsev
ere.
•Cl
ear c
omm
unic
atio
n be
twee
n al
l mem
bers
of t
he te
am le
ads
to su
cces
sful
out
com
es.
•Es
tabl
ishin
g a
rela
tions
hip
with
the
phys
icia
ns a
s an
ally
is a
n im
port
ant f
ound
atio
nal s
tep.
•O
ngoi
ng e
duca
tion
and
mon
itorin
g do
cum
enta
tion
requ
irem
ents
is e
ssen
tial.
•St
ay fo
cuse
d an
d ce
lebr
atin
g ou
r win
s.
BIGG
EST
LESS
ONS
LEAR
NED
TEAM
MEM
BERS
M
irand
a Ha
milt
on, I
CU M
ange
r/AC
E Te
am, A
lley
DaSi
lva,
Crit
ical
Ca
re E
duca
tor,
Mar
y Sy
me,
ED
educ
ator
, Gw
en H
elm
uth,
Q
ualit
y/PI
Sep
sis D
ata
Abst
ract
or, M
arily
n St
ockm
an D
irect
or
Qua
lity/
PI, A
ndre
w B
attle
s, D
irect
or C
ritic
al C
are
Serv
ices
, Am
y Be
nson
, Dire
ctor
Pha
rmac
y, Sh
irley
Hei
ntz,
CN
O, a
ll nu
rse
man
ager
s, n
urse
cha
mpi
ons f
rom
eac
h un
it, S
andy
Wai
sner
and
Ce
Ce S
esso
n, IT
, Dr
. Adi
ga, D
r. M
arx,
Dr.
Spen
cer,
Dr. L
ogga
n, a
nd
Dr. D
ay.
•La
ck o
f rec
ogni
tion
of se
psis
by th
e he
alth
care
team
•La
ck o
f sup
port
by
the
med
ical
staf
f for
the
seps
is re
com
men
datio
ns e
spec
ially
with
con
cern
s rel
ated
to fl
uid
over
load
•In
cons
isten
t use
of L
H se
psis
scre
enin
g to
ol•
Inco
nsist
ent
med
ical
man
agem
ent o
f sep
sis p
atie
nts w
ith
inco
nsist
ent u
se o
f Sep
sis O
rder
Set
s•
Inco
nsist
ent d
ocum
enta
tion
by n
ursin
g an
d ph
ysic
ians
•U
ncle
ar ro
le e
xpec
tatio
ns w
ith th
e AC
E te
am•
Clar
ity a
nd a
ccur
acy
of c
odin
g•
Com
mun
icat
ions
thro
ugho
ut th
e co
ntin
uum
Ove
rall
seps
is ra
te h
as in
crea
sed
with
impr
oved
reco
gniti
on b
y th
e he
alth
care
team
.
Ove
rall
seps
is m
orta
lity
rate
was
bel
ow th
e ta
rget
7
Seps
is I
mm
ersi
on P
roje
ct
Sain
t Fr
anci
s H
ealth
care
Sys
tem
Jenn
i Myr
acle
, BSN
, RN
, CCR
N &
Car
la C
rum
p, B
SN, R
N
PRO
JECT
FO
CUS
•Sa
int
Fran
cis
Med
ical
Cen
ter
(SFM
C)
Emer
genc
y D
epar
tmen
t ob
serv
ed a
sub
optim
al
67%
3-h
our
bund
le c
ompl
ianc
e. A
dditi
onal
ly,
SFM
C id
entif
ied
that
Sep
sis
reco
gniti
on w
as
our
chie
f opp
ortu
nity
for
impr
ovem
ent.
•G
oal/A
im S
tate
men
t: I
mpr
ove
3-ho
ur S
epsi
s Bu
ndle
Com
plia
nce
by 5
0% (
from
67%
to
84%
) on
or
befo
re 1
Sep
tem
ber
2016
.
INIT
IAL
PRO
JECT
BAR
RIER
S ID
ENTI
FIED
KEY
SOLU
TIO
NS
IMPL
EMEN
TED
KEY
LESS
ON
S LE
ARN
ED
RETU
RN O
N I
NVE
STM
ENT
Proj
ect
plan
is t
o be
gin
mea
surin
g th
e fo
llow
ing
afte
r im
plem
entin
g th
e 6-
hour
Bu
ndle
:a.
Len
gth
of s
tay
b. V
entil
ator
day
sc.
Cos
t pe
r Ca
sed.
Sep
sis
Reco
gniti
on R
ate
e. C
odes
out
side
of
the
ICU
rel
ated
to
Seps
is
RESU
LTS
TEAM
ACC
OM
PLIS
HM
ENTS
a. I
mpr
oved
Sep
sis
Reco
gniti
onb.
Ear
ly G
oal D
irect
ed T
hera
pyc.
Ach
ieve
d >
50%
ove
rall
3-ho
ur B
undl
e Co
mpl
ianc
e go
al.
Phys
icia
n an
d nu
rsin
g ed
ucat
ion
rela
ted
to
Seps
is:
a. S
urvi
ving
Sep
sis
crite
ria v
. “ru
le o
f 10
0s”
b. C
ultu
re s
hift
“Se
psis
unt
il pr
oven
oth
erw
ise”
c. 3
-hou
r Se
psis
bun
dle
d. I
dent
ifica
tion
and
man
agem
ent
of S
eptic
Sho
cke.
Ord
erin
g la
ctic
aci
d v.
pro
calc
itoni
n.
•H
ouse
wid
e ed
ucat
ion
on S
epsi
s.•
Seps
is s
cree
ning
too
l bui
lt in
to E
MR.
•Se
psis
tic
k sh
eet
deve
lope
d to
driv
e co
mpl
ianc
e w
ith 3
-hou
r bu
ndle
.•
Activ
ated
“Be
st P
ract
ice
Advi
sory
” w
hen
SIRS
crit
eria
met
.•
Impl
emen
ted
nurs
e-dr
iven
Sep
sis
prot
ocol
s fo
r us
e in
ED
and
inpa
tient
dep
artm
ents
. •
Com
plet
e ca
se r
evie
ws
on a
ll fa
ll ou
ts a
nd
iden
tify
area
s of
impr
ovem
ent.
Pro
ject
Tas
ksFo
rm p
roce
ss im
prov
emen
t te
ams
& d
evel
op t
eam
str
uct
ure
Com
plet
e
Com
plet
e a
min
i-fa
ilure
mod
es e
ffec
ts a
nal
ysis
(FM
EA)
Com
plet
e
Def
ine
the
proj
ect
Scop
eCo
mpl
ete
Rev
iew
Su
rviv
ing
Seps
is B
un
dle
& d
evel
op p
lan
for
impl
emen
tati
onCo
mpl
ete
Impl
emen
t u
se o
f a
Rap
id R
espo
nse
Team
(R
RT)
Kit
Com
plet
e
Sele
ct E
duca
tion
al r
esou
rces
to
be u
tiliz
ed f
or s
taff
Com
plet
e
Sele
ct p
atie
nt
& f
amily
edu
cati
onal
res
ourc
esCo
mpl
ete
Def
ine
& im
plem
ent
Seps
is A
udi
t to
ols
for
trac
kin
g co
mpl
ian
ceCo
mpl
ete
Pro
cess
in p
lace
to
ensu
re b
road
spe
ctru
m a
nti
biot
ic a
dmin
iste
red
wit
hin
3 h
ours
Com
plet
e
Hig
h le
vel o
f si
tuat
ion
al a
war
enes
s re
gard
ing
Seps
is r
ecog
niti
on a
nd
inte
rven
tion
Com
plet
e
Staf
f ed
uca
tion
su
rvey
reg
ardi
ng e
arly
rec
ogni
tion
of
sign
s an
d sy
mpt
oms
of S
epsi
sCo
mpl
ete
Con
firm
ed a
nd
valid
ated
dai
ly a
udi
t to
ols
com
plet
e
Enga
ge E
D/
EMS
lead
ersh
ipCo
mpl
ete
Obs
erve
d au
dits
bei
ng
com
plet
ed, r
evie
wed
for
tre
nds
.Co
mpl
ete
Spot
ch
eck
obse
rvat
ion
s fo
r re
al t
ime
audi
ts
Com
plet
e
Rev
iew
bar
rier
sCo
mpl
ete
Rev
iew
pro
ject
impl
emen
tati
on f
or R
OI
& p
atie
nt
safe
ty a
chie
vem
ent
Com
plet
e
CL33
.03%
17.6
5%
UCL
0.59
23
0.44
60
0.06
83
0%10%
20%
30%
40%
50%
60%
70%
80%
90%
Oct
201
5N
ov 2
015
Dec
201
5Ja
n 20
16Fe
b 20
16M
ar 2
016
Apr
2016
May
201
6Ju
n 20
16Ju
l 201
6Au
g 20
16
# of Fallouts/Total # of Sepsis Cases presenting in the ED
Mon
th -
Yea
r
Seps
is 3
-hou
r B
undl
e Fa
llout
s in
the
ED
(Oct
ober
201
5 -
Aug
ust
2016
)
Bet
ter
Seps
is I
mm
ersi
onPr
ojec
t be
gins
, M
arch
201
6.
Impl
emen
t ED
Sep
sis
Scre
enin
g, A
pril
2016
.
Dep
loye
dSe
psis
Tic
k Sh
eet
in
ED, J
une
2016
.
0.47
%
0.40
%0.
40%
0.23
%
0.58
%
0.71
%
0.81
%
0.87
%
0.79
%
0.69
%
0.47
%CL
0.47
%
0.72
%
UCL
0.00
79
0.01
14
LCL
0.00
15
0.00
31
0.0%
0.2%
0.4%
0.6%
0.8%
1.0%
1.2%
1.4%
Oct
201
5N
ov 2
015
Dec
201
5Ja
n 20
16Fe
b 20
16M
ar 2
016
Apr
2016
May
201
6Ju
n 20
16Ju
l 201
6Au
g 20
16
% of Recognized Sepsis Cases per Month
Mon
th -
Yea
r
Seps
is R
ecog
niti
on
(O
ctob
er 2
015
-A
ugus
t 20
16)
Bet
ter
8
Capi
tal R
egio
n M
edic
al C
ente
rCA
UTI
Imm
ersi
on P
roje
ct
KEY
SOLU
TION
S IM
PLEM
ENTE
D•
Com
plia
nce
Audi
ts–
Perfo
rm ro
utin
e au
dits
of c
ompl
ianc
e w
ith
mai
nten
ance
bun
dle
•N
urse
Driv
en P
roto
col–
Deve
lop
and
impl
emen
t a n
urse
driv
en
cath
eter
rem
oval
pro
toco
l
•Ed
ucat
e st
aff o
n al
tern
ate
met
hods
, pur
chas
e m
ore
blad
der s
cann
ers,
ob
tain
con
dom
cat
hete
r opt
ion.
•Ca
thet
er S
ecur
emen
t–Ev
alua
te c
urre
nt se
cure
men
t dev
ice,
edu
cate
st
aff o
n pr
oper
use
of s
ecur
emen
t dev
ice
•Fo
ley
Days
–de
crea
se n
umbe
r of d
ays c
athe
ter i
s lef
t in
plac
e
IDEN
TIFI
ED B
ARRI
ERS
TO P
ROJE
CT
SUCC
ESS
BIGG
EST
ACCO
MPL
ISH
MEN
TS
•Ze
ro C
AUTI
s for
383
day
s
•Em
brac
ed a
lead
ersh
ip a
nd a
ccou
ntab
ility
stru
ctur
e ac
ross
the
orga
niza
tion
•Im
plem
ente
d pr
oces
s im
prov
emen
t bas
ed o
n ev
iden
ce b
ased
be
st p
ract
ices
that
dem
onst
rate
d m
easu
reab
le re
sults
•En
hanc
ed p
atie
nt sa
fety
thro
ugh
impr
oved
out
com
es
NEX
T ST
EPS
FOR
SUST
AINA
BILI
TY
Char
ts
Pict
ures
COST
SAV
INGS
BIGG
EST
LESS
ONS
LEAR
NED
TEAM
MEM
BERS
•Te
am c
onsis
ted
of V
P N
ursin
g, In
fect
ion
Prev
entio
nist
, nur
se m
anag
er, 2
be
dsid
e nu
rses
, IT,
phy
sicia
n (s
urge
on),
nurs
e ed
ucat
or
•Did
not
hav
e a
proc
ess t
o au
dit m
aint
enan
ce b
undl
e co
mpl
ianc
e
•Wer
e no
t util
izing
a n
urse
driv
en c
athe
ter r
emov
al p
roto
col
•Alte
rnat
ive
met
hods
to c
athe
teriz
atio
n w
ere
not b
eing
rout
inel
y co
nsid
ered
•Cat
hete
rs w
ere
left
in g
reat
er th
an 3
day
s
•Da
ily m
aint
enan
ce b
undl
e au
dits
hei
ghte
n st
aff a
war
enes
s
•Im
port
ant t
o in
volv
e be
dsid
e st
aff &
phy
sicia
ns in
pro
toco
l de
velo
pmen
t
•N
urse
pro
toco
l em
bedd
ed in
to e
lect
roni
c m
edic
al re
cord
aid
s ear
ly
disc
ontin
uatio
n of
cat
hete
r
•Al
low
ade
quat
e tim
e fo
r sta
ff &
phy
sicia
n ed
ucat
ion
•Re
vise
d pr
oces
s for
ED
base
d on
if p
atie
nt w
as d
ischa
rged
hom
e or
ad
mitt
ed
•Es
timat
ed c
ost p
er e
vent
= $
1,00
0
•#
CAU
TI’s
in 2
015
= 8
•20
16 C
AUTI
cos
t sav
ings
= $
8,00
0
•Pa
tient
pai
n &
suffe
ring
RESU
LTS
CAU
TI p
er p
atie
nt d
ay:
Base
line
= 0.
19 (2
015)
Goal
= .1
1 (4
0% re
duct
ion)
Curr
ent =
.05
(AW
ESO
ME!
)
•Dai
ly m
aint
enan
ce b
undl
e au
dits
will
con
tinue
•Pro
vide
supp
ortiv
e en
viro
nmen
t and
just
in ti
me
educ
atio
n as
staf
f &
phys
icia
ns b
ecom
e co
mfo
rtab
le w
ith u
sing
nurs
e ca
thet
er re
mov
al
prot
ocol
•Red
ucin
g ha
rms i
s par
t of o
rgan
izatio
n da
shbo
ard
FACI
LITY
ATT
RIBU
TES
•100
bed
rura
l hos
pita
l
•150
0 em
ploy
ees
•21,
000
Adm
issio
ns
9
[PO
TTY
!-D
on’t
CA
UTI
]N
orth
Kan
sas
City
Hos
pita
l CAU
TI T
eam
mem
bers
: A
lison
Ros
s, B
SN, R
N, P
CCN
, Bec
ky S
mith
, MSN
c, R
N, C
IC,
Clau
dia
Fren
ch, R
N, B
SN, C
IC, D
eana
Gia
lde,
MLS
(ASC
P)SM
CM, D
ebbi
e Fl
athe
rs, J
enni
fer
Reno
, BSN
, RN
, CM
SRN
, Ju
dy S
prin
ger,
M.S
., RN
, Lin
dsey
McN
erne
y, R
N, B
SN, C
IC, L
ynn
Smith
MH
A, B
SN, R
N, C
PHQ
, Mic
helle
Sul
livan
, RN
, BSN
, MBA
, Pau
l Mun
dy, R
N, B
SN, P
CCN
, Reb
ecca
Mur
rell,
MBA
, BSN
, RN
, San
dra
Mer
ritt,
BSN
, RN
, CCR
N,
Shar
on H
unt,
BSN
, RN
, St
acy
Kear
ns, B
SN, R
N, C
EN a
nd T
odd
Fulle
rton
, MH
A, B
SN, R
N
PRO
JECT
FO
CUS
Cath
eter
-ass
ocia
ted
urin
ary
trac
t in
fect
ion
(CAU
TI)
is t
he m
ost
com
mon
hea
lth c
are-
asso
ciat
ed in
fect
ion
in t
he U
.S.
Follo
win
g ev
iden
ce b
ased
pra
ctic
e fo
r in
sert
ion
and
mai
nten
ance
, and
dec
reas
ing
cath
eter
ut
iliza
tion
have
bee
n pr
oven
met
hods
to
decr
ease
CAU
TI.
•Ph
ase
1-Fo
cuse
d ed
ucat
ion
of b
undl
e pr
actic
es•
Phas
e 2
-Nur
se D
riven
Fol
ey R
emov
al
Prot
ocol
INIT
IAL
PRO
JECT
BAR
RIER
S ID
ENTI
FIED
•W
ould
Med
ical
Sta
ff s
uppo
rt t
his
Prot
ocol
?•
Wou
ld N
ursi
ng s
taff
fee
l com
fort
able
im
plem
entin
g su
ch a
Pro
toco
l?•
Coul
d th
e el
ectr
onic
med
ical
rec
ord
docu
men
tatio
n su
ppor
t th
e Pr
otoc
ol?
•W
hat
are
the
pote
ntia
l con
sequ
ence
s of
in
appr
opria
te F
oley
rem
oval
?
KEY
SOLU
TIO
NS
IMPL
EMEN
TED
•Po
licy
deve
lopm
ent
base
d on
evi
denc
e ba
sed
guid
elin
es•
Nur
se r
emov
al P
roto
col a
ppro
val a
nd
impl
emen
tatio
n•
Elec
tron
ic m
edic
al r
ecor
d re
visi
on t
o ge
nito
urin
ary
asse
ssm
ent
KEY
LESS
ON
S LE
ARN
ED•
Com
mun
icat
ion
is k
ey:
com
mun
icat
e in
a
varie
ty o
f w
ays.
•Tr
ansi
tion
from
phy
sici
an d
riven
to
nurs
e em
pow
ered
pra
ctic
e is
a jo
urne
y.•
Educ
atio
n is
key
; in
clud
ing
Med
ical
St
aff
and
Nur
sing
POTT
Y!-D
on’t
CAU
TI
trav
elin
g aw
ard
RESU
LTS/
RETU
RN O
N I
NVE
STM
ENT
•Pr
e-in
terv
entio
n (P
hase
1 an
d 2)
Yea
r 20
15
SIR
0.34
. Pha
se 1
(Q
1 20
16)
SIR
0.33
, Ph
ase
2 (Q
2 20
16)
SIR
0.0.
•N
ursi
ng s
atis
fact
ion:
em
pow
erm
ent
and
auto
nom
y w
ith a
vaila
bilit
y of
Pro
toco
l•
Dec
reas
ed u
rine
spec
imen
con
tam
inat
ion
rate
s po
st im
plem
enta
tion
RESU
LTS
TEAM
ACC
OM
PLIS
HM
ENTS
Conc
lusi
on 1
–Fu
ll im
plem
enta
tion
of
Nur
se D
riven
Fol
ey R
emov
al P
roto
col
Conc
lusi
on 2
–Id
entif
ied
docu
men
tatio
n ga
ps w
ithin
the
EM
R
Conc
lusi
on 3
–Tr
avel
ing
awar
d fo
r th
e un
it th
at d
ecre
ases
util
izat
ion
the
mos
t w
ith n
o in
fect
ion—
POTT
Y!-D
on’t
CAU
TI
•Fi
rst
Qua
rter
Tas
ks =
71
%•
Seco
nd Q
uart
er T
asks
=
50%
•Th
ird Q
uart
er T
asks
=
30%
024681012
Apr-
16M
ay-1
6Ju
n-16
Jul-1
6
Number of times protocol used/ 1000 Foley Days
Mon
th
Num
ber o
f Pro
toco
l Doc
umen
ted
Use
s/ 1
000
Fole
y Da
ys
*Pro
toco
l may
be
utili
zed
mor
e th
an w
hat i
s cap
ture
d by
doc
umen
tatio
n
10
Imm
ersi
on P
ilot P
roje
ct: N
orth
wes
t Med
ical
Ce
nter
’s C
AUTI
Red
ucti
on In
itia
tive
[
KEY
SOLU
TION
S IM
PLEM
ENTE
D•
Phys
icia
n/st
aff e
duca
tion
on e
vide
nce
base
d pr
actic
es.
•Em
ploy
ed n
urse
-driv
en re
mov
al p
roto
col
•Do
cum
ente
d ho
urly
roun
ding
initi
ated
.•
Impr
oved
eas
e of
man
agem
ent i
n th
e EM
R em
ploy
ed.
IDEN
TIFI
ED B
ARRI
ERS
TO P
ROJE
CT
SUCC
ESS
BIGG
EST
ACCO
MPL
ISH
MEN
T
•N
ot e
mpl
oyin
g a
Nur
se-D
riven
Rem
oval
Pro
toco
l.•
A kn
owle
dge
defic
it by
affe
cted
staf
f.•
No
clea
r cha
mpi
on fo
r red
uctio
n an
d no
bur
ning
des
ire to
ch
ange
pra
ctic
e.•
Ord
er se
ts th
at w
ere
allo
win
g m
issed
opp
ortu
nitie
s for
Ca
thet
er R
emov
al.
TASK
S %
COM
PLET
ION
AN
D RE
SULT
S
•Li
st fi
rst q
uart
er ta
sk c
ompl
etio
n 10
0%•
List
seco
nd q
uart
er ta
sk c
ompl
etio
n 75
%•
List
third
qua
rter
task
com
plet
ion
100%
COST
SAV
INGS
•
With
an
aver
age
cost
of 1
000
dolla
rs p
er C
AUTI
to th
e fa
cilit
y, pr
even
tion
of 1
.5 C
AUTI
’s du
ring
this
proj
ect
save
d N
MC
appr
oxim
atel
y 15
00 d
olla
rs a
nd e
limin
ated
th
e ne
ed fo
r inc
reas
ed m
onito
ring
and
trea
tmen
ts. I
t al
so, d
ecre
ased
the
num
ber o
f unn
eces
sary
and
pr
even
tabl
e ho
spita
l day
s. T
he p
ositi
ve o
utco
mes
for t
he
patie
nts p
rovi
ded
by th
e ne
wly
impl
emen
ted
prev
entio
n to
ols a
nd te
chni
ques
is w
hat N
MC
is ce
lebr
atin
g.
BIGG
EST
LESS
ONS
LEAR
NED
HOS
PITA
L IN
FORM
ATIO
N A
ND
TEAM
MEM
BERS
•W
e le
arne
d th
at n
urse
’s ar
e m
anag
ing
the
cath
eter
s.•
The
nurs
e-dr
iven
rem
oval
pro
toco
l was
not
use
d ef
ficie
ntly,
ph
ysic
ians
wer
e no
t ord
erin
g it.
•Ev
iden
ce-b
ased
pra
ctic
es w
ere
avai
labl
e bu
t, no
t bei
ng
utili
zed.
•W
e le
arne
d th
at w
e w
ere
not r
ound
ing
with
pur
pose
.•
Roun
ds w
ere
bein
g do
ne b
ut it
ems w
ere
not c
ompl
eted
ba
sed
on th
e be
st p
ract
ice
chec
klist
.
•W
e ha
d to
mak
e do
ing
the
“rig
ht th
ing”
the
eas
y th
ing
to
do.
•Ed
ucat
ion
on e
vide
nce
base
d pr
actic
es a
nd th
e nu
rse-
driv
en
prot
ocol
wer
e sh
ared
at m
ed st
aff.
•Ch
ange
s to
simpl
ify th
e EM
R or
der s
ets w
ere
impl
emen
ted.
Nor
thw
est M
edic
al C
ente
r is a
25
bed
Criti
cal A
cces
s hos
pita
l lo
cate
d in
Alb
any,
Mo.
pro
vidi
ng A
cute
, Sw
ing
bed,
and
Em
erge
ncy
serv
ices
Ave
rage
dai
ly c
ensu
s=7.
1A
nnua
l ED
visit
s =29
00P
hysic
ian
Clin
ics=
4
Dr. J
acki
e M
iller
-Cha
mpi
on a
nd IP
M
ed D
irect
or
Lori
Bish
op-IP
Nur
seSa
rah
Foun
tain
-Lab
Dire
ctor
Tr
acy
Osb
orn-
Nur
sing
Dire
ctor
Kent
Wils
on-E
.S. D
irect
orRi
ck H
oltm
an-S
urge
ry N
urse
Aliso
n So
rens
on-a
t lar
ge m
embe
rDe
nise
Man
ion-
Secr
etar
y
•N
MC
wan
ted
to d
ecre
ase
CAU
TI’s
in o
ur fa
cilit
y, on
all
units
, by
40%
wor
king
with
in th
e de
fined
tim
efra
me
of
Oct
ober
201
5-Ju
ly 2
016.
•As
ide
from
the
obvi
ous b
enef
its to
pat
ient
s, o
utco
mes
an
d th
e bo
ttom
line
; NM
C is
mos
t pro
ud o
f set
ting
this
loft
y go
al a
nd a
chie
ving
it, t
hrou
gh d
edic
atio
n an
d th
e ha
rd w
ork
of th
e ca
regi
vers
invo
lved
.
14.2
13.1
9.34
6.71
0246810121416
FY 2
013
FY 2
014
FY 2
015
FY 2
016
CAU
TI Im
prov
emen
t Pro
ject
Nor
thw
est M
edic
al C
ente
r
CAU
TI's
per 1
000
line
days
CUSP
pro
ject
thro
ugh
HEN
1.0
.6-
13
Evid
ence
bas
ed p
ract
ice
team
in
itiat
ed. 4
-201
4
Nur
se D
riven
Rem
oval
Pro
toco
l in
pl
ace.
1-20
15
Bega
n pa
rtic
ipat
ion
in H
EN 2
.0
CAU
TI Im
mer
sion.
9-2
015
SUST
AINA
BILI
TY A
ND
SPRE
AD P
LAN
•N
MC
will
con
tinue
to su
ppor
t/au
dit t
his p
rogr
am a
nd
educ
ate
staf
f on
evid
ence
-bas
ed m
etho
ds to
sust
ain
the
prog
ress
we
have
mad
e an
d in
vest
in c
ontin
uing
to
impr
ove
and
effe
ct p
ositi
ve o
utco
mes
for o
ur p
atie
nts
thro
ugh
new
tool
s and
reco
mm
enda
tions
, as t
hey
beco
me
avai
labl
e.
NEX
T ST
EPS/
FUTU
RE P
LAN
S•
We
will
con
tinue
to a
sses
s the
effe
ctiv
enes
s of t
his
prog
ram
and
look
for e
duca
tion
and
grow
th
oppo
rtun
ities
.•
NM
C is
goin
g to
tria
l the
Qua
laris
tool
for c
ontin
ued
roun
ding
and
follo
w u
p. W
e un
ders
tand
this
has b
een
a va
luab
le to
ol fo
r ide
ntify
ing
area
s for
impr
ovem
ent.
•Th
e CA
UTI
initi
ativ
e w
ill b
e m
onito
red
thro
ugh
the
IPAC
pr
ogra
m, m
ovin
g fo
rwar
d.
11
Was
hing
ton
Cou
nty
Mem
oria
l Hos
pita
l’s
CA
UTI
Im
mer
sion
Pro
ject
Anto
inet
te A
den
RN, J
enife
r Fe
rgus
on R
N M
SN, B
ever
ly W
illia
ms
RN B
SN, M
issy
Cal
law
ay R
N B
SN,
Ther
esa
Gol
den
RN B
SN, S
arah
Gib
son
RN B
SN, P
atti
Koch
RN
, & N
icho
le B
oyer
RN
WH
Y W
ORK
ON
CAU
TI?
•W
ashi
ngto
n Co
unty
was
see
ing
Fole
ys
inse
rted
with
out
prop
er r
easo
n•
Fole
y us
age
rem
aine
d hi
gh•
Blad
der
scan
s w
ere
obso
lete
•In
fect
ions
occ
urre
d du
e to
unn
eces
sary
an
d ex
tend
ed u
se o
f ca
thet
ers
•N
urse
s w
ere
not
cons
iste
nt in
the
ir m
aint
enan
ce o
r ch
artin
g of
cat
hete
rs
WH
AT B
ARRI
ERS
WER
E ID
ENTI
FIED
?
CHAN
GES
TH
AT M
ADE
A D
IFFE
REN
CE
•Ed
ucat
ion
with
ED
sta
ff a
nd n
ursi
ng u
nit
staf
f•
Chan
ged
EHR
to in
clud
e be
tter
cha
rtin
g in
GU
se
ctio
n•
Dai
ly r
ound
ing
with
cha
rge
nurs
e an
d pr
imar
y nu
rse
•Ch
ange
d Fo
ley
cath
eter
s th
at w
ere
avai
labl
e
WH
AT D
ID W
E LE
ARN
?•
ED s
taff
inse
rted
cat
hete
rs t
oo f
requ
ently
•St
raig
ht c
athe
ters
wer
e no
t be
ing
used
for
ur
inar
y re
tent
ion
•O
ur F
oley
s di
d no
t co
me
with
a r
ed s
eal
•Ch
artin
g w
as in
cons
iste
nt•
Cath
eter
mai
nten
ance
was
inco
nsis
tent
HAR
D W
ORK
CRE
ATES
IM
PRO
VEM
ENT
BIG
WIN
S!
•Fe
wer
CAU
TIS
•Fe
wer
cat
hete
r da
ys•
Impr
oved
cha
rtin
g•
Nur
ses
mor
e en
gage
d w
ith p
atie
nts
•N
urse
s m
ore
awar
e of
cat
hete
r pr
otoc
ols
3
4
2
00.
511.
522.
533.
544.
5
2014
2015
2016
HAI
CAU
TI
# C
AUTI
sLi
near
(#
CAU
TIs)
685
517
306
0
100
200
300
400
500
600
700
800
2014
2015
2016
Cath
eter
Day
s
Cath
eter
Day
sLi
near
(Ca
thet
er D
ays)
•St
aff
educ
atio
n•
Crite
ria fo
r in
sert
ion
•M
aint
enan
ce•
Tim
ely
rem
oval
•Bl
adde
r sc
ans
wer
e ne
ver
done
•Po
or c
hart
ing
•Ph
ysic
ian
supp
ort
of n
urse
driv
en p
roto
col
DID
TH
E W
ORK
MAK
E A
DIF
FERE
NCE
?
CAU
TI I
MM
ERSI
ON
PRO
JECT
TEA
M
•YE
S!
It w
as w
orth
it!
•Co
mpa
red
to b
asel
ine
data
the
cha
nges
in
our
wor
kflo
w m
ade
a di
ffere
nce
•W
e pr
even
ted
3 pe
ople
from
hav
ing
a CA
UTI
!•
We
also
sav
ed $
3,00
0
12
Cox
Med
ical
Cen
ter
Bra
nson
OB
Har
m:
Pre
ecla
mps
ia M
anag
emen
tCo
x M
edic
al C
ente
r Br
anso
n is
a 1
40 b
ed r
ural
fac
ility
abo
ut 1
hou
r so
uth
of S
prin
gfie
ld, M
isso
uri w
ith a
prim
arily
low
-inco
me
patie
nt p
opul
atio
n.
The
labo
r an
d de
liver
y un
it is
a le
vel 2
A an
d ha
s 3
labo
r ro
oms,
2 t
riage
roo
ms,
7 p
ost
part
um r
oom
s , 1
OR
suite
, and
ave
rage
sof
600
del
iver
ies
per
year
.
PRO
JECT
FO
CUS
Impr
ove
early
war
ning
sig
n re
cogn
ition
and
in
crea
se a
war
enes
s of
pre
ecla
mps
ia s
igns
an
d sy
mpt
oms
acro
ss t
he c
ontin
uum
.
INIT
IAL
PRO
JECT
BAR
RIER
S ID
ENTI
FIED
•Co
xHea
lth S
yste
m p
olic
y fo
r Pr
eecl
amps
ia C
are
Gui
delin
es &
OB
Hyp
erte
nsiv
e Cr
isis
ord
er s
ets
wer
e in
cons
iste
nt a
mon
g th
e th
ree
faci
litie
s w
ith a
labo
r an
d de
liver
y un
it.•
Afte
r ho
urs
phys
icia
n co
vera
ge
Mos
t de
liver
ies
are
perf
orm
ed b
y Fa
mily
Pr
actic
e/O
B ph
ysic
ians
tha
t ha
ve c
linic
dur
ing
the
day
and
take
cal
l aft
er h
ours
O
ften
the
re a
re o
nly
1-2
ED p
hysi
cian
s in
hou
se
shou
ld t
here
be
an e
mer
genc
y•
Mul
tiple
poi
nt o
f en
try,
whi
ch w
ould
req
uire
ed
ucat
ion
and
incr
ease
d aw
aren
ess
Cl
inic
vis
its, p
hone
tria
ge, O
B tr
iage
, pr
esen
tatio
n to
the
Em
erge
ncy
Dep
artm
ent
KEY
SOLU
TIO
NS
IMPL
EMEN
TED
•Co
mpl
eted
blo
od p
ress
ure
educ
atio
n w
ith c
linic
and
in
patie
nt s
taff
•Im
plem
ente
d us
e of
the
Pre
ecla
mps
ia E
arly
Re
cogn
ition
Too
l (PE
RT)
in O
B &
ED
•Im
plem
ente
d us
e of
Pre
gnan
cy C
ompl
icat
ion
Educ
atio
n at
all
loca
tions
of
patie
nt d
isch
arge
•
Upd
ated
Cox
Hea
lthSy
stem
pol
icy
for
Pree
clam
psia
G
uide
lines
& O
B H
yper
tens
ive
Cris
is o
rder
set
to
stan
dard
ize
acro
ss t
he t
hree
fac
ilitie
s•
Initi
ated
rea
l-tim
e tr
acki
ng o
f bl
ood
pres
sure
m
anag
emen
t m
edic
atio
ns g
iven
in L
abor
& D
eliv
ery
•Be
gan
elec
tron
ic t
rack
ing
com
plic
atio
ns a
ssoc
iate
d w
ith h
yper
tens
ive
diso
rder
s in
pre
gnan
cy
KEY
LESS
ON
S LE
ARN
ED•
Incl
usio
n of
mem
bers
fro
m a
ll de
part
men
ts im
pact
ed
by t
he p
roje
ct w
as e
ssen
tial i
n cr
eatin
g bu
y-in
am
ong
the
hosp
ital s
taff
•As
a H
ealth
Sys
tem
, it
is v
ital t
o en
sure
tha
t al
l fa
cilit
ies
have
pol
icie
s &
ord
er s
ets
in p
lace
tha
t ar
e up
to
date
with
evi
denc
e ba
sed
prac
tice
& n
otify
the
ot
her
faci
litie
s w
hen
chan
ges
are
need
ed
Per
cent
of
Pro
ject
Qua
rter
ly T
asks
C
ompl
eted
Qua
rter
110
0% (
8/8)
Qua
rter
210
0% (
7/7)
Qua
rter
310
0% (
6/6)
TEAM
MEM
BERS
RESU
LTS
NEX
T ST
EPS
Und
erst
andi
ng o
ur c
urre
nt p
roce
sses
was
impe
rativ
e pr
ior
to id
entif
ying
gap
s
Acco
rdin
g to
Pou
rat
et a
l. th
e co
st a
ssoc
iate
d w
ith
com
plic
atio
ns f
rom
hyp
erte
nsio
n, p
reec
lam
psia
and
ec
lam
psia
exc
eed
$100
,000
per
del
iver
y.
In f
isca
l yea
r 20
15 w
e ha
d 4
case
s w
ith
com
plic
atio
ns w
here
as fo
r fis
cal y
ear
2016
the
re
have
bee
n no
cas
es
Base
d on
the
se e
stim
ates
our
faci
lity
has
pote
ntia
lly s
aved
nea
rly $
400,
000
thro
ugh
coor
dina
ted
pree
clam
psia
man
agem
ent
Pour
atN
, Mar
tinez
AE,
Jon
es, J
M, G
rego
ry K
D, K
orst
L, K
omin
skiG
F. C
osts
of G
esta
tiona
l Hyp
erte
nsiv
e D
isor
ders
in C
alifo
rnia
: H
yper
tens
ion,
Pre
ecla
mps
ia, a
nd E
clam
psia
. Los
Ang
eles
(CA
): U
CLA
Cent
er fo
r H
ealth
Pol
icy
Rese
arch
; 20
13.
•D
evel
opin
g an
ele
ctro
nic
tran
sfer
qua
lity
mea
sure
re
port
for
mom
’s a
nd/o
r ba
bies
tha
t ar
e tr
ansf
erre
d to
Spr
ingf
ield
’s c
ampu
s fo
r a
high
er le
vel o
f ca
re
Aim
to
impr
ove
tran
sfer
pro
cess
&
com
mun
icat
ion
betw
een
faci
litie
s an
d id
entif
y op
port
uniti
es t
o im
prov
e pa
tient
out
com
es•
Dev
elop
a p
hone
tria
ge p
roce
ss a
imed
at
impr
ovin
g th
e ea
rly r
ecog
nitio
n an
d ea
rly in
terv
entio
n•
Use
of
the
Mat
erna
l Obs
tetr
ic E
arly
War
ning
cha
rt t
o m
ake
pop-
up a
lert
s in
Cer
ner
Pow
erCh
art
to in
crea
se
awar
enes
s in
rea
l tim
e w
hen
a pa
tient
is e
xhib
iting
ea
rly s
igns
of
pree
clam
psia
•Co
xHea
lth’s
Criti
cal A
cces
s H
ospi
tal i
n M
onet
t co
mpl
eted
FM
EA in
Mar
ch 2
016
and
bega
n in
itiat
ing
actio
n ite
ms
rela
ted
to id
entif
ied
gaps
•St
anda
rdiz
ed p
olic
y an
d po
wer
pla
n am
ong
the
thre
e ho
spita
ls in
Cox
Hea
lthSy
stem
.•
Plan
to
initi
ate
sim
ulat
ions
to
read
y st
aff
for
emer
gent
O
B si
tuat
ions
at
all p
oint
s of
ent
ry
SPRE
AD P
LAN
Wen
dy H
usto
n, N
urse
man
ager
OB,
Tea
m L
eade
rLa
cy P
hilli
ps, R
N, F
acili
tato
rD
r. Ca
tieBe
nbow
, Phy
sici
an C
ham
pion
Lynn
e Ya
ggy,
RN
, MSN
, CN
O, S
enio
r Le
ader
Cha
mpi
onTr
acey
Will
iam
s, M
SN, F
NP,
Tea
m M
embe
rKi
m U
nruh
, RN
, Nur
se m
anag
er E
R, T
eam
Mem
ber
Laur
a Pa
ul, R
N, S
taff
nur
se C
CU, T
eam
Mem
ber
Don
na D
onab
edia
n, R
N, S
taff
Nur
se O
B, T
eam
mem
ber
Sum
mer
Fro
nter
hous
e, R
N, O
B Cl
inic
Nur
se, T
eam
mem
ber
13
Imm
ersi
on P
ilot P
roje
ct: H
yper
tens
ion
in P
regn
ancy
KEY
SO
LUTI
ON
S IM
PLEM
ENTE
DHy
pert
ensi
on
Algo
rithm
IDEN
TIFI
ED B
ARRI
ERS
TO
PRO
JECT
SU
CCES
S
KEY
SO
LUTI
ON
S IM
PLEM
ENTE
D
•Ed
ucat
ion
•Ph
ysic
ians
•Al
l Fam
ily B
irth
Cent
er st
aff
•Cl
inic
Sta
ff•
1 ye
ar la
ter-
educ
atio
n ag
ain
base
d on
id
entif
ied
barr
iers
TASK
S %
CO
MPL
ETIO
N
•1st
Qua
rter
-100
%
NEX
T ST
EPS
•Em
erge
ncy
Room
•Do
cum
enta
tion
chan
ges
•Ed
ucat
ion
•Ad
ditio
n of
ER
team
mem
ber
•Co
mm
unic
atio
n-Be
dsid
e re
port
HTN
qu
estio
n m
anda
tory
•Cu
lture
Cha
nge-
2 ho
ur P
P re
cove
ry 1
on
1•
Daily
Aud
it
BIGG
EST
LESS
ON
S LE
ARN
ED
TEAM
MEM
BERS
•Dr
. Afr
assia
b-ph
ysic
ian
cham
pion
•M
ary
Lou
Gam
m R
NC-
OB,
Nur
se M
anag
er•
Min
dy T
ibbe
n RN
C-O
B•
Laur
en C
obb,
RN
•En
sure
nur
ses a
re m
ore
acut
ely
awar
e of
ne
ed fo
r clo
se o
bser
vatio
n of
PP
patie
nts f
or
HTN
•Co
mm
unic
atio
n be
twee
n la
bor a
nd n
urse
an
d ne
xt o
ncom
ing
PP n
urse
•
Char
t rev
iew
s on
fall
outs
for e
ach
RN•
Send
fall
outs
to p
hysic
ians
•Dr
ill m
ore
than
ann
ually
Ecla
mps
iaAl
gorit
hmEa
rly
Reco
gniti
on T
ool
•Res
istan
ce to
trea
tmen
t•A
wai
ting
epid
ural
pla
cem
ent
•BP
r/t p
ain
or p
ushi
ng•C
hron
ic h
yper
tens
ion
vs. p
re-e
clam
psia
•Cul
ture
–Cl
oser
obs
erva
tion
requ
ired,
pa
rtic
ular
ly im
med
iate
PP
reco
very
•Re
sour
ces
•HT
N b
inde
r at d
esk
•Tr
eatm
ent a
lgor
ithm
in d
raw
er in
eve
ry
room
•Ea
rly re
cogn
ition
and
trea
tmen
t al
gorit
hm o
n pa
tient
’s te
al c
lipbo
ard
•Ec
lam
psia
Resp
onse
•La
nyar
ds w
ith ro
les d
etai
led
•Di
rect
ions
for m
edic
atio
ns-s
peci
fic a
nd
simpl
e•
Tox
Box-
orga
nize
d an
d cl
early
labe
led
•Si
mul
atio
ns
•Aw
aren
ess
•Te
al b
lue
fold
ers a
nd c
lipbo
ards
•Bl
ue p
atie
nt h
ando
uts
•Hu
ddle
s an
d Ce
nsus
shee
t with
HTN
and
PP
H ad
dres
sed
on e
ach
patie
nt•
Mea
sure
on
ever
y co
mpu
ter
•M
onth
ly c
hart
revi
ew p
ublis
hed
•2nd
Qua
rter
-80%
•Da
ily A
udit
•Em
erge
ncy
Room
•3rd
Qua
rter
-90%
•
Emer
genc
y Ro
om•
PDCA
•Tr
ish Ju
ng, R
NC-
OB
•Ke
lli W
ater
s, O
B-PC
T
14
CAU
TI R
EDU
CTIO
N F
OR
A H
OSP
ITAL
SYS
TEM
U
sing
Lea
n M
etho
dolo
gy
KEY
SOLU
TION
S IM
PLEM
ENTE
D
•Re
duce
pat
ient
har
m fr
om H
ospi
tal A
cqui
red
CAU
TI fo
r pat
ient
s at a
larg
e,
hete
roge
neou
s hea
lth sy
stem
in th
e M
idw
est b
y 10
% y
ear o
ver y
ear
•Re
duce
cat
hete
r day
s thr
ough
nur
se-d
riven
pro
toco
ls fo
r avo
idan
ce o
f cat
hete
rs
and
cath
eter
rem
oval
IDEN
TIFI
ED B
ARRI
ERS
TO P
ROJE
CT
SUCC
ESS
BIGG
EST
ACCO
MPL
ISH
MEN
T •
For t
he S
aint
Luk
e’s H
ealth
Sys
tem
Co
mm
unity
and
Crit
ical
Acc
ess
hosp
itals
(9 h
ospi
tals)
onl
y 1
CAU
TI
for 2
016
year
to d
ate
•Su
ccee
ded
in th
e ad
aptiv
e ch
ange
of
unde
rsta
ndin
g CA
UTI
as p
atie
nt h
arm
EXAM
PLES
OF
TOOL
KIT
COM
PON
ENTS
COST
SAV
INGS
BIGG
EST
LESS
ONS
LEAR
NED
TEAM
MEM
BERS
•CA
UTI
redu
ctio
n is
very
diff
icul
t (bu
t not
impo
ssib
le) t
he c
ritic
al
care
env
ironm
ent
•Co
mm
unity
hos
pita
ls w
ith th
e ab
ility
to d
o re
al-t
ime
obse
rvat
ions
pro
vide
s the
bes
t env
ironm
ent f
or ra
pid
cycl
e im
prov
emen
t•
“Ter
min
al u
niqu
enes
s” is
a h
uge
barr
ier
•Ze
ro is
an
achi
evab
le g
oal
•Ef
fect
ive
qual
ity im
prov
emen
t wor
k is
loca
l
GOAL
S
En
gage
d fr
ont l
ine
staf
f in
wor
k te
ams t
o re
duce
CAU
TI
Deve
lope
d to
ol k
it in
clud
ing
actio
n pl
ans,
com
mun
icat
ion
brie
fings
, obs
erva
tion
tool
s
Chan
ged
the
EMR
(EPI
C) to
mak
e nu
rse
driv
en p
roto
col m
ore
visib
le
Chan
ged
and
educ
ated
on
polic
y ch
ange
s
Deve
lope
d “r
oll u
p” ru
n ch
art t
o co
ntin
ue a
ctiv
e m
onito
ring
In
crea
se m
indf
ulne
ss a
roun
d pa
tient
har
m th
roug
h th
e us
e of
pat
ient
stor
ies
Im
plem
ente
d IT
cha
nges
to d
rive
corr
ect c
are,
incl
udin
g el
imin
atin
g th
e “a
-la c
arte
” fo
ley
orde
r
Revi
sed
orde
r set
s to
alig
n fo
ley
indi
catio
ns w
ith p
ublis
hed
evid
ence
Ed
ucat
ed a
nd a
udite
d th
e fo
ley
care
bun
dle
Em
phas
ized
robu
st p
eric
are
for c
ritic
al c
are
patie
nts
N
ew W
ork:
U
nive
rsal
CHG
bat
hing
for p
atie
nts w
ith a
fole
yca
thet
er
Dat
e of
Inse
rtio
n:__
__/_
___/
____
Tim
e:__
____
__U
nit:
____
____
____
__
Fax
ed: b
y___
____
__If
ther
e is
a d
evia
tion
in a
ny o
f the
cri
tical
step
s, im
med
iate
ly n
otify
the
inse
rter
and
stop
the
proc
edur
e un
til c
orre
cted
.U
ncor
rect
ed d
evia
tions
and
com
plic
atio
ns o
f lin
e pl
acem
ent a
re to
be
repo
rted
in R
iskM
aste
r.
Inse
rted
By:
____
____
____
____
____
____
____
____
O
bser
ver:
____
____
____
____
____
____
____
____
Gen
der:
Mal
e in
serti
on
Fem
ale
inse
rtion
Tim
e O
ut P
erfo
rmed
Bef
ore
Proc
edur
e
Ver
ify O
rder
Patie
nt M
eets
Indi
catio
n of
: A
ccur
ate
I&O
Acu
te R
eten
tion
Com
fort
/ Pal
liativ
e C
are
Exte
nded
Imm
obili
zatio
n
Ope
n Sa
cral
Wou
nd
Uro
logy
Pat
ient
/ U
RO
surg
ery
Risk
s an
d be
nefit
s ex
plai
ned,
pat
ient
edu
catio
n pr
ovid
ed
Prep
arat
ion
Gat
her p
rope
r sup
plie
s (K
it, sp
ecia
lty c
athe
ter i
f nee
ded)
Perfo
rm h
and
hygi
ene
and
don
clea
n gl
oves
Ope
n ou
ter p
acka
ging
, rem
ove
tray
and
open
kit
to e
xpos
e un
der p
ad, s
oap,
and
san
itize
r
Plac
e un
der p
ad b
enea
th p
atie
nt’s
per
i are
a w
ith s
hiny
sid
e do
wn
Use
Cas
tile
Soap
wip
es to
clea
nse
patie
nt’s
per
i-ure
thra
l are
a
Disc
ard
glov
es a
nd p
erfo
rm h
and
hygi
ene
with
pro
vide
d al
coho
l han
d sa
nitiz
er g
el
Ase
ptic
Inse
rtio
n
Don
ster
ile g
love
s
Posit
ion
fene
stra
ted
drap
e on
pat
ient
app
ropr
iate
ly
Atta
ch th
e w
ater
-fille
d sy
ringe
to th
e in
flatio
n po
rt (N
ote i
t is
not n
eces
sary
to p
re-te
st th
e ba
lloon
)
Lubr
icat
e ca
thet
er w
ith lu
bric
ant t
hat i
s pl
aced
into
tray
top
Cle
anse
pat
ient
’s u
reth
ra /
peri
area
with
pac
ket o
f pre
-sat
urat
ed an
tisep
tic s
wab
stic
ks
Inse
rt ca
thet
er u
ntil
urin
e is
visib
le in
the
drai
nage
tube
If pr
oper
cat
hete
rizat
ion
is no
t acc
ompl
ished
, use
a N
EWca
thet
er fo
r fut
ure
atte
mpt
s
Adv
ance
cat
hete
r as i
ndic
ated
to en
sure
fully
in b
ladd
er
Infla
te c
athe
ter b
allo
on w
ith a
ttach
ed sy
ringe
usin
g en
tire
10m
l of s
teril
e w
ater
Ease
cat
hete
r bac
k by
gen
tly p
ullin
g on
cat
hete
r unt
il sli
ght t
ensio
n is
dete
cted
Afte
r th
e Pr
oced
ure,
Did
the
Inse
rter
:
Secu
re F
oley
cat
hete
r with
sta
t-loc
kPo
sitio
n co
llect
ion
bag
on b
ed ra
il be
low
the
blad
der l
evel
Use
gre
en sh
eetin
g cl
ip to
secu
re d
rain
age
tube
to sh
eet
Con
firm
tub
e is
not k
inke
dIn
dica
te ti
me
and
date
of c
athe
ter i
nser
tion
on p
rovi
ded
oran
ge la
bels
and
plac
e on
the
drai
nage
sys
tem
.Pr
ovid
e pa
tient
with
edu
catio
n pa
mph
let i
n ki
tD
iscar
d al
l use
d su
pplie
s an
d gl
oves
and
per
form
han
d hy
gien
eD
ocum
ent t
he p
roce
dure
in E
PIC
Not
es:
MIN
DFU
LNES
S
Jul 1
6M
ay 1
6M
ar 1
6Ja
n 16
Nov
15
Sep
15Ju
l 15
May
15
Mar
15
Jan
15
12 10 8 6 4 2 0
Mon
th
Individual Value
_ X=3.1
3
UCL=
11.86
Befo
reAf
ter
CAU
TI C
ount
for E
ntire
Sai
nt L
uke'
s Sy
stem
CAU
TI R
educ
tion
Proj
ect B
egan
Dec
embe
r 201
5Co
nclu
sion
: No
Impr
ovem
ent O
ccur
red
X=2.
82
P-va
lue=
0.76
3si
gnifi
cant
diff
eren
ce.
befo
re a
nd a
fter
data
: No
2 Sa
mpl
e T-
test
com
parin
g
A3
Met
hod
olog
y
Im
plem
entin
g an
d sp
read
ing
relia
ble
proc
esse
s acr
oss a
syst
em le
vel a
t var
ious
hos
pita
ls an
d pr
actic
e gr
oups
requ
ires l
ocal
eng
agem
ent a
nd p
roce
ss m
odifi
catio
ns
Adap
tive
issue
s sur
roun
ding
cat
hete
r ass
ocia
ted
urin
ary
trac
t inf
ectio
n, in
clud
ing
the
notio
n of
this
even
t as h
arm
requ
ires n
ew a
ppro
ache
s
Ther
e m
ay b
e a
low
er le
vel w
here
redu
cing
cat
hete
r day
s in
the
criti
cal c
are
popu
latio
n is
not p
ossib
le
Barb
ara
Ball,
MSN
, RN
Alic
ia B
eebe
, BSN
, MH
A, R
ND
enni
s Bee
rs, M
Div
, MBA
, BSN
, RN
, NE-
BC, C
PHQ
Caro
lyn
Blac
kbur
n, B
SN,R
NG
inny
Boo
s, M
SN, R
N, C
PHQ
Mel
Bow
en, B
AN,R
N, C
PHQ
, MA
Jodi
Bro
wn
Nat
alie
Bus
h,RN
Celia
Cru
m, R
NCh
eryl
Dav
is, R
N, B
SN,C
ICAm
anda
Dul
ing,
MS,
LSS
MBB
Chris
tina
Fraz
ier
Alan
a G
oerin
ger,
RN,
BA, M
HA,
CCR
N
Cath
erin
e H
amilt
onCi
ndy
Lars
on ,
BSN
,RN
Des
iree
Mon
aco,
RN
, BSN
, CCR
NJo
ann
Paul
, RN
, MSN
Kim
berly
Ric
hard
son,
CPH
QBe
verly
Sha
ul, R
NCh
ristin
e Sm
ith, R
N, B
SNAn
gela
Sny
der,
RN, B
SNJe
nnife
r Son
nenm
oser
, RN
Shau
na T
hom
pson
, RH
IT,A
MS,
LSS
BBLo
rriW
ilbur
n, R
NM
argo
Will
iam
s, B
SN, R
ND
ebbi
e W
ilson
, RN
, MH
A,M
SND
ebbi
e W
riedt
, CPH
RM, M
HA,
RH
IT
15
Impr
ovin
g th
e Tr
eatm
ent o
f Hyp
erte
nsiv
e E
mer
genc
y A
ngel
Ols
on R
N, V
alor
ie K
ohou
tek
RN
, Abb
y Pr
offe
r MD
, Eva
Sha
y R
N, S
hana
Het
t RN
, Li
sann
e M
ilfor
d R
N, B
riann
e Fa
llon
RN
, Mea
gan
Bla
ir R
N
Bac
kgro
und
Ear
ly tr
eatm
ent o
f hyp
erte
nsio
n ha
s co
nsis
tent
ly b
een
foun
d to
redu
ce th
e in
cide
nce
of h
yper
tens
ive
cris
is. D
ata
from
mul
tiple
cas
e st
udie
s re
veal
ed
incr
ease
d ra
tes
of h
eart
failu
re, p
ulm
onar
y ed
ema,
stro
ke a
nd d
eath
whe
n an
tihyp
erte
nsiv
e m
edic
atio
ns w
ere
not u
sed
in w
omen
with
sev
ere
gest
atio
nal
hype
rtens
ion
or s
ever
e pr
eecl
amps
ia.1
Acc
ordi
ng to
the
Am
eric
an C
ongr
ess
of
Obs
tetri
cian
s an
d G
ynec
olog
ists
(AC
OG
), a
hype
rtens
ive
emer
genc
y is
def
ined
as
an
acut
e -on
set,
seve
re h
yper
tens
ion
pers
istin
g fo
r 15
min
utes
or m
ore.
2
Trea
tmen
t sho
uld
be in
itiat
ed fo
r blo
od p
ress
ures
exc
eedi
ng ≥
160
mm
Hg
syst
olic
or 1
05-1
10 m
m H
g di
asto
lic w
ithin
30-
60 m
inut
es.3
The
prim
ary
goal
is to
re
duce
mat
erna
l int
racr
ania
l hem
orrh
age,
whi
ch re
mai
ns th
e le
adin
g ca
use
of
deat
h fro
m p
reec
lam
psia
. IV
Hyd
rala
zine
, IV
labe
talo
l and
ora
l nife
dipi
near
e th
e th
ree
“firs
t lin
e” a
gent
s us
ed to
trea
t hyp
erte
nsiv
e em
erge
ncy
in p
reec
lam
psia
.A
qual
ity im
prov
emen
t pro
ject
was
des
igne
d to
impr
ove
the
reco
gniti
on o
f hy
perte
nsiv
e em
erge
ncy
by c
linic
ians
and
impr
ove
the
rate
of a
ntih
yper
tens
ive
ther
apy
in le
ss th
an 6
0 m
inut
es in
this
pat
ient
pop
ulat
ion.
Initi
al B
arrie
rs Id
entif
ied
A st
aff s
urve
y va
lidat
ed a
kno
wle
dge
gap
in a
cro
ss-s
ectio
n of
clin
icia
ns. S
urve
y re
sults
dem
onst
rate
d 26
% o
f nur
ses
and
50%
of p
hysi
cian
s co
rrec
tly id
entif
ied
the
BP
para
met
ers
for h
yper
tens
ive
emer
genc
y. C
hart
revi
ew re
veal
ed a
di
spar
ity in
man
agem
ent o
f the
se p
atie
nts
with
onl
y 23
.8%
of h
yper
tens
ive
emer
genc
ies
rece
ivin
g ap
prop
riate
ant
ihyp
erte
nsiv
e th
erap
y.
.
Key
Sol
utio
ns Im
plem
ente
d
•17
7 La
bor a
nd D
eliv
ery,
Ant
epar
tum
, and
Pos
tpar
tum
nur
ses
and
60
com
mun
ity O
BG
YN
and
fam
ily p
ract
ice
phys
icia
ns w
ere
requ
ired
to
com
plet
e th
e on
e ho
ur h
yper
tens
ive
emer
genc
y si
mul
atio
n to
mai
ntai
n th
eir
priv
ilege
s
•A
ll P
erin
atal
Nur
ses
requ
ired
to a
ttend
one
hou
r Hyp
erte
nsiv
e E
mer
genc
y di
dact
ic p
rese
nted
by
our O
B H
ospi
talis
ts
•W
eekl
y H
uddl
e to
pics
wer
e pr
esen
ted
durin
g sh
ift h
uddl
e, b
y em
ail,
and
disp
laye
d on
the
unit
to p
rovi
de b
road
er fo
unda
tion
of p
atho
phys
iolo
gy a
nd
the
treat
men
t of p
reec
lam
psia
•M
onth
ly C
hart
Aud
its o
f pre
gnan
t and
pos
tpar
tum
hyp
erte
nsiv
e pa
tient
s,
follo
w u
ps d
one
dire
ctly
with
clin
icia
ns c
arin
g fo
r pat
ient
s w
ith h
yper
tens
ive
emer
genc
y
•E
duca
ting
team
for u
tiliz
atio
n th
e cr
eatin
ine:
prot
ein
ratio
in p
lace
of t
he 2
4 ho
ur u
rine
Nur
sing
is a
driv
ing
forc
e to
impr
ove
the
qual
ity o
f car
e w
e pr
ovid
e. E
duca
tion
of n
ursi
ng la
ys th
e fra
mew
ork
for a
cha
nge
in p
ract
ice.
Sta
ff hu
ddle
s is
an
effe
ctiv
e w
ay to
brin
g in
form
atio
n to
the
team
. Eng
agin
g ph
ysic
ian
cham
pion
s to
adv
ocat
e fo
r the
util
izat
ion
of e
vide
nce
base
d pr
otoc
ols
is a
n ef
fect
ive
cata
lyst
for c
hang
e.
Less
ons
Lear
ned
Res
ults
Sust
aina
bilit
y
Ref
eren
ces
1. M
agee
LA,
Aba
los
E, v
on D
adel
szen
P, S
ibai
B, E
aste
rling
T, W
alki
nsha
w S
. How
to
man
age
hype
rtens
ion
in p
regn
ancy
effe
ctiv
ely.
Br J
Clin
Pha
rmac
ol. S
ep 2
011;
72(3
):394
-401
.2.
AC
OG
. Com
mitt
ee O
pini
on n
o. 6
23: E
mer
gent
ther
apy
for A
cute
-Ons
et, S
ever
e H
yper
tens
ion
Dur
ing
Preg
nanc
y an
d th
e Po
stpa
rtum
Per
iod
3. A
CO
G. D
iagn
osis
and
Man
agem
ent o
f Pre
ecla
mps
ia a
nd E
clam
psia
#33
. Am
eric
an
Con
gres
s of
Obs
tetri
cian
s an
d G
ynec
olog
ists
Pra
ctic
e B
ulle
tin N
umbe
r33
. 200
2 (R
eaffi
rmed
201
2).
•C
ontin
ued
audi
ts b
y pe
rinat
al e
duca
tor t
o sp
ot c
heck
trea
tmen
t rat
e•
Opp
ortu
nity
for i
mpr
ovem
ent w
ith E
mer
genc
y D
epar
tmen
t Tea
m
Com
pute
r bas
ed le
arni
ng p
reec
lam
psia
mod
ule
for a
ll E
D s
taff
E
D p
atie
nt c
hart
revi
ews
with
Em
erge
ncy
Roo
m p
rovi
ders
H
yper
tens
ive
emer
genc
y si
mul
atio
ns w
ith E
D te
am•
Lunc
h an
d Le
arn
over
Hyp
erte
nsio
n in
Pre
gnan
cy o
pen
to a
ll cl
inic
ians
at
SM
MC
giv
en b
y M
FM a
nd C
ardi
olog
ist
Team
Acc
ompl
ishm
ents
•E
mpo
wer
ing
beds
ide
nurs
es to
bec
ome
enga
ged
and
be p
art o
f the
cha
nge
•Im
prov
e st
aff a
war
enes
s of
pre
ecla
mps
ia a
nd c
onfid
ence
in tr
eatm
ent
algo
rithm
s•
Impr
ovin
g th
e tre
atm
ent o
f hyp
erte
nsiv
e em
erge
ncy
from
23.
8% to
87.
5%
23.8
48.6
59
72
85
43
72
87.5
Oct
-14
Jul-
15O
ct-1
5M
ar-1
6A
pr-1
6M
ay-1
6Ju
n-16
Jul-
16
treatment %
TR
EAT
MEN
T W
ITH
AN
TIH
YPE
RT
ENSI
VE
16
Pre
vent
ing
Rea
dmis
sion
sTe
am M
embe
rs:
Dr.
Mar
k G
alan
t (H
ospi
talis
t), Ca
rol L
ewis
(Q
ualit
y M
anag
emen
t),
Jenn
ifer
Schm
ehl R
N (
Med
ical
-Sur
gica
l Uni
t M
anag
er),
Je
nnife
r Kl
inks
ick
RN (
CCU
/Tel
e U
nit
Man
ager
), C
hery
l Moh
r (P
atie
nt S
ervi
ces
Uni
t M
anag
er),
Mar
k Jo
nes
RPh,
Car
men
Mat
ter
RN (
Infe
ctio
n Co
ntro
l), R
ebec
ca T
arve
r RN
(CN
O),
Car
issa
Mar
grav
e RN
(Ed
ucat
ion
Coor
dina
tor)
PRO
JECT
FO
CUS
•Th
e go
al o
f th
is p
roje
ct is
to
redu
ce 3
0 da
y al
l cau
se r
eadm
issi
ons
by 1
0%•
To im
plem
ent
diag
nost
ic s
cree
ning
crit
eria
fo
r pa
tient
bar
riers
to
care
and
pre
vent
ion
of r
eadm
issi
ons
by f
lagg
ing
thos
e at
ris
k
INIT
IAL
PRO
JECT
BAR
RIER
S ID
ENTI
FIED
KEY
SOLU
TIO
NS
IMPL
EMEN
TED
KEY
LESS
ON
S LE
ARN
ED•
The
LACE
sco
re d
id n
ot w
ork
wel
l for
our
fa
cilit
y. O
ver
80%
of
our
patie
nts
are
at
high
ris
k fo
r re
adm
issi
on.
•A
tran
sitio
nal p
lan
betw
een
the
clin
ic a
nd
hosp
ital i
s im
prov
ing.
We
are
wor
king
on
a di
seas
e pr
oces
s pl
an o
f ca
re t
o be
un
iver
sal b
etw
een
the
two.
•Th
e do
ctor
s ar
e m
ore
awar
e of
the
pe
rcen
tage
s of
pat
ient
s th
ey r
eadm
it, a
nd
are
tryi
ng t
o pr
even
t av
oida
ble
read
mis
sion
s.
RESU
LTS/
RETU
RN O
N I
NVE
STM
ENT
RESU
LTS
TEAM
ACC
OM
PLIS
HM
ENTS
•Ca
re p
aths
cre
ated
bet
wee
n th
e ru
ral
heal
th c
linic
s an
d th
e ho
spita
l.•
Scre
enin
g to
ols
iden
tifie
d an
d im
plem
ente
d to
scr
een
ever
y pa
tient
fo
r a
“Ris
k fo
r Re
adm
issi
on”
•Es
tabl
ishe
d a
scre
enin
g to
ol f
or t
he
soci
al w
orke
r to
app
ropr
iate
ly s
cree
n fo
r ba
rrie
rs t
o ca
re a
t ho
me.
•Am
ped
up t
he e
duca
tion
for
staf
f, ph
ysic
ians
and
pat
ient
’s in
pre
vent
ing
unne
cess
ary
read
mis
sion
s.•
Adde
d ad
ditio
nal d
isch
arge
inst
ruct
ions
to
mee
t M
HA
reco
mm
enda
tions
.
•N
on-c
ompl
ianc
e of
the
pat
ient
•D
octo
r no
n-co
mpl
ianc
e•
Com
mun
ity r
esou
rces
lim
ited
•LA
CE s
core
was
impl
emen
ted
to f
lag
patie
nts
at h
igh
risk
for
read
mis
sion
•Ba
rrie
rs t
o co
mpl
ianc
e w
ith d
isea
se
man
agem
ent
are
asse
ssed
and
ad
dres
sed.
•Pa
tient
’s ar
e ed
ucat
ed a
bout
m
edic
atio
ns, d
iagn
osis
, man
agem
ent
of
dise
ase
proc
ess,
hom
e ca
re in
stru
ctio
ns
prio
r to
dis
char
ge.
•Pa
tient
’s ar
e sc
hedu
led
at t
heir
pref
erre
d tim
e of
day
for
follo
w u
p ap
poin
tmen
ts
on M
onda
y–Fr
iday
s.•
Dis
char
ge p
hone
cal
ls a
re m
ade
with
in
24-4
8 ho
urs
afte
r di
scha
rge.
PERC
ENT
OF
QU
ARTE
RLY
TASK
S CO
MPL
ETED
•Th
e ho
spita
l sav
ed m
oney
by
prev
entin
g un
nece
ssar
y re
adm
issi
ons.
•Ti
me
was
not
sav
ed d
ue t
o m
anua
l ext
ract
ion
of d
ata.
•N
o m
ater
ials
wer
e w
aste
d. W
e am
ped
up o
ur
educ
atio
n an
d es
tabl
ishe
d co
ntin
uity
of
care
be
twee
n th
e ru
ral h
ealth
clin
ic a
nd t
he
hosp
ital.
•O
ur o
utco
mes
impr
oved
for
sev
eral
mon
ths
and
stay
ed b
elow
the
cur
rent
nat
iona
l ave
rage
of
15%
•Fi
rst
quar
ter
task
com
plet
ion:
71
%•
List
sec
ond
quar
ter
task
co
mpl
etio
n: 1
00%
•Li
st t
hird
qua
rter
tas
k co
mpl
etio
n: 9
0%, u
nabl
e to
im
plem
ent
all t
asks
with
in t
he 3
m
onth
per
iod
17
Imm
ersi
on P
ilot P
roje
ct: R
eadm
issi
ons
[
KEY
SOLU
TION
S IM
PLEM
ENTE
D•
Lace
Tool
Impl
emen
ted-
staf
f edu
catio
n, d
iscus
sed
in d
aily
in
terd
epar
tmen
tal c
linic
al h
uddl
es. M
edic
al H
ome
care
co
ordi
natio
n in
volv
ed w
ith p
ost c
are
follo
w u
p. P
harm
acy
cons
ulte
d an
d pe
rfor
med
med
icat
ion
revi
ew w
ith h
igh
risk
patie
nts a
nd fa
mily
.•
Early
iden
tific
atio
n of
Car
egiv
er a
nd P
CP•
Emph
asize
d pr
oper
doc
umen
tatio
n an
d te
achb
ack
met
hods
IDEN
TIFI
ED B
ARRI
ERS
TO P
ROJE
CT
SUCC
ESS
BIGG
EST
ACCO
MPL
ISH
MEN
T •
Depa
rtm
ents
bec
ame
mor
e en
gage
d an
d aw
are
of
owni
ng th
eir p
ortio
n of
the
patie
nt d
ischa
rge
and
read
miss
ion
proc
ess.
•In
crea
sed
com
mun
icat
ion
betw
een
staf
f, pa
tient
s and
fa
mili
es.
•Gr
eate
r str
eam
lined
doc
umen
tatio
n re
sulti
ng in
bet
ter
patie
nt o
utco
mes
and
impr
oved
staf
f wor
kflo
w.
TASK
S %
COM
PLET
ION
•Fi
rst Q
uart
er 1
00%
•Se
cond
Qua
rter
71%
•Th
ird Q
uart
er 2
9%
COST
SAV
INGS
•
No
retu
rn o
n in
vest
men
t can
be
calc
ulat
ed a
s of t
his d
ate.
BIGG
EST
LESS
ONS
LEAR
NED
TEAM
MEM
BERS
•
Bria
n O
yler
-Pha
rmac
ist, K
im T
arka
-PI C
oord
inat
or, D
iana
Ta
ylor
-Med
ical
Hom
e Di
rect
or,
Jole
ne W
arre
n-Di
rect
or
of C
are
Coor
dina
tion,
Pat
ricia
Col
e-Ca
re C
oord
inat
or,
Vale
rie N
oblit
t-Ho
me
Heal
th D
irect
or
•Th
roug
h th
e Ge
mba
we
iden
tifie
d va
rious
met
hods
of d
ischa
rge
teac
hing
and
teac
hbac
k.•
We
did
not h
ave
an a
dequ
ate
proc
ess i
n pl
ace
to v
alid
ate
Care
give
rs o
r ide
ntify
ing
patie
nts w
ho d
id n
ot c
urre
ntly
hav
e a
PCP
to fo
llow
up
with
pos
t disc
harg
e.
•W
e w
ere
able
to u
tilize
our
EM
R to
link
to o
ur e
lect
roni
c pa
tient
co
mm
unic
atio
n bo
ards
. By
doin
g th
is w
e ar
e ab
le to
co
mm
unic
ate
to p
atie
nts/
fam
ilies
/anc
illar
y st
aff a
nd n
ursin
g st
aff t
he re
adm
issio
n ris
k an
d Ca
regi
ver f
or th
e pa
tient
.
Enga
ging
all
depa
rtm
ents
in o
wni
ng th
eir
port
ion
of th
e pa
tient
disc
harg
e an
d re
adm
issio
n pr
even
tion
proc
ess.
•W
e w
ill c
ontin
ue to
wor
k on
our
cur
rent
pro
cess
es fo
r m
edic
atio
n re
conc
iliat
ion
acro
ss th
e CM
H O
rgan
izatio
n an
d ou
r ex
tern
al c
usto
mer
s.
•Co
ntin
ue to
focu
s on
the
impo
rtan
ce o
f pre
vent
ativ
e re
adm
issio
ns to
ach
ieve
the
goal
of b
ette
r hea
lth, b
ette
r car
e an
d to
ulti
mat
ely
low
er c
osts
for o
ur p
atie
nts.
•Du
e to
une
xpec
ted
turn
over
in k
ey p
ositi
ons,
will
be
focu
sing
on
trai
ning
and
edu
catin
g ne
w m
anag
ers a
nd s
taff.
NEX
T ST
EPS
Elec
tron
ic B
oard
s now
disp
lay
the
Prim
ary
Care
give
r an
d th
e Re
adm
issio
n ris
k, g
lean
ed fr
om th
e EM
R do
cum
enta
tion.
Be
fore
A
fter
18
Star
ting
the
Jou
rney
to
Red
ucin
g 30
day
Rea
dmis
sion
s (A
ll C
ause
)Li
bert
y H
ospi
tal
Libe
rty
Mis
sour
i
PRO
JECT
FO
CUS
•R
educ
e av
oida
ble
read
mis
sion
s fo
r Lib
erty
Hos
pita
l pa
tient
s.
•P
rovi
de ti
mel
y ev
iden
ce-b
ased
com
mun
icat
ion
and
educ
atio
n to
pat
ient
s, fa
mili
es, s
taff
and
our
com
mun
ity h
ealth
car
e pa
rtner
s.•
.
INIT
IAL
PRO
JECT
BAR
RIER
S ID
ENTI
FIED
•Pa
tient
and
fam
ily w
ishe
s.•
Conf
lictin
g da
ta, c
odin
g, a
nd a
naly
sis
of w
hy
we
cont
inue
d to
hav
e re
adm
issi
ons
•Co
mm
unic
atio
n be
twee
n pa
tient
/fam
ily, s
taff
, pr
ovid
ers,
and
car
e m
anag
ers
with
dis
char
ge
plan
ning
and
acc
epta
nce.
•Ph
ysic
ian
unde
rsta
ndin
g an
d ac
cept
ance
ad
aptin
g to
reg
ulat
ory
com
plia
nce
•Al
tern
ativ
e se
rvic
es a
vaila
ble
for
disc
harg
e.
KEY
SOLU
TIO
NS
IMPL
EMEN
TED
Co
mpl
etio
n of
a R
eadm
issi
on P
roje
ct P
lan
St
ruct
ure
com
plet
ed f
or w
ork
com
plet
ion:
Ev
eryo
ne is
onb
oard
Su
bcom
mitt
ees
are
mee
ting
and
prog
ress
ing
with
th
eir
wor
k
We
are
on t
he jo
urne
y….
KEY
LESS
ON
S LE
ARN
ED
Invo
lve
the
patie
nt a
nd f
amily
as
early
as
poss
ible
w
ith d
isch
arge
pla
nnin
g.
It t
akes
a v
illag
e!
In
clus
ion
and
clea
r co
mm
unic
atio
n be
twee
n al
l m
embe
rs o
f th
e co
ntin
uum
of
care
for
eac
h pa
tient
is
ess
entia
l.
Part
ners
hip
with
the
phy
sici
ans
is e
ssen
tial.
Pr
oces
s ev
alua
tion.
RESU
LTS/
RETU
RN O
N I
NVE
STM
ENT
Com
plet
ion
of P
roje
ct P
lan
with
impl
emen
tatio
nno
t lo
ng e
noug
h to
see
the
impa
ct
RESU
LTS
TEAM
ACC
OM
PLIS
HM
ENTS
-Co
mm
unic
atio
n be
twee
n te
am m
embe
rs is
pi
vota
l to
succ
ess
-Ac
cura
cy in
cod
ing
is a
key
com
pone
nt in
re
flect
ing
the
who
le s
tory
-Th
e te
am m
ust
faci
litat
e ph
ysic
ian
unde
rsta
ndin
g an
d bu
y in
to
be s
ucce
ssfu
l
Pro
ject
Lea
d: D
enni
e An
ders
on, D
irect
or C
are
Man
agem
ent,
Dr.
Ragh
aven
dra
Adig
a, M
edic
al D
irect
or C
are
Man
agem
ent,
and
M
arily
n St
ockm
an, D
irect
or Q
ualit
y an
d Pe
rfor
man
ce I
mpr
ovem
ent.
P
roje
ct T
eam
: A
ndre
w B
attle
s, A
my
Bens
on, N
ancy
Bue
hrer
, Ja
cque
Dav
is, J
ackl
yn G
entr
y, M
irand
a H
amilt
on, L
isa
Han
son,
Kim
H
arris
, Shi
rley
Hei
ntz,
Bra
d Jo
hnso
n, D
iane
Kip
ping
, Sha
rla L
eon,
Jo
di M
cCla
naha
n, A
mie
McD
onal
d, W
endy
Mill
igan
, Lis
a M
oral
es,
Jean
ne N
emec
, Xan
dria
Tho
mas
, Den
ise
Trec
caric
he,
Mic
helle
Tr
emai
n, J
udy
Wag
ner,
Jan
Wat
kins
, Dan
Will
iam
s, a
nd C
athy
G
russ
ing.
Re
pres
ents
: D
epar
tmen
t D
irect
ors,
pha
rmac
y, f
inan
ce,
nurs
es, N
NP’
s, t
hera
pies
, IT,
edu
catio
n, C
are
Man
agem
ent,
Soc
ial
Wor
kers
, Hos
pice
, Hom
e H
ealth
, Phy
sici
an O
ffic
e M
anag
ers
and
othe
r co
mm
unity
hea
lthca
re p
artn
ers.
M
edic
al S
taff
mem
bers
-D
r. So
unda
rraj
, Dr.
Spen
cer,
Dr.
Day
, Dr.
Mar
x, D
r. B.
Car
lson
, and
Dr.
Loga
n
19
OM
C R
eadm
issi
on I
mm
ersi
on P
roje
ct
PRO
JECT
FO
CUS
•30
day
rea
dmis
sion
s fo
r AM
I, C
HF,
Pn
eum
onia
, CO
PD, T
otal
Joi
nts,
CAB
G,
Stro
ke &
Sep
sis
with
sec
onda
ry d
iagn
osis
of
pne
umon
ia.
•Fo
cus
area
s:
ICU
, Ste
pdow
n, a
nd
Med
/Sur
g•
Med
icat
ion
Reco
ncili
atio
n at
Dis
char
ge•
Accu
rate
Dis
char
ge I
nstr
uctio
ns•
Mul
tidis
cipl
inar
y Ro
undi
ng
INIT
IAL
PRO
JECT
BAR
RIER
S ID
ENTI
FIED
•D
iffer
ent
EMR
in E
D (
T-Sy
stem
), I
npat
ient
(M
edite
ch)
and
Clin
ics
(Alls
crip
ts)
and
not
ever
yone
had
acc
ess
to a
ll sy
stem
s.
•Pi
lot
with
Mul
tidis
cipl
inar
y ro
unds
in I
CU h
ad m
orph
ed
into
gra
nd r
ound
s w
ith o
nly
pulm
onol
ogy
part
icip
atio
n an
d no
pat
ient
or
fam
ily p
artic
ipat
ion
•Ph
ysic
ian
part
icip
atio
n w
ith p
ilot
was
virt
ually
nil
•D
isch
arge
med
icat
ions
&
in
stru
ctio
ns t
hrou
gh M
edite
chw
ere
diff
icul
t to
edi
t •
No
phar
mac
y te
chs
to a
ssis
t w
ith M
edic
atio
n Re
conc
iliat
ion
KEY
SOLU
TIO
NS
IMPL
EMEN
TED
•H
ouse
wid
e nu
rsin
g ed
ucat
ion
for
editi
ng d
isch
arge
in
stru
ctio
ns s
o th
at “
Plai
n La
ngua
ge”
and
patie
nt
spec
ific
inst
ruct
ions
con
sist
ently
use
d•
Util
izin
g pa
tient
whi
tebo
ards
to
docu
men
t LA
CE s
core
, av
erag
e LO
S fo
r th
eir
spec
ific
DRG
with
exp
ecte
d di
scha
rge
date
and
dis
char
ge d
ispo
sitio
n•
Mul
tidis
cipl
inar
y ro
undi
ng s
tart
ed 3
/1/1
6 in
the
foc
us
area
s-cr
eate
d a
“Cas
e M
anag
emen
t” r
ound
ing
note
in
Med
itech
that
is e
asily
acc
essi
ble
for
the
phys
icia
ns•
Patie
nt “
Stop
light
s” in
inco
rpor
ated
into
the
dis
char
ge
rout
ine
in M
edite
chfo
r ta
rget
dia
gnos
es•
Med
icat
ion
reco
ncili
atio
n is
stil
l a w
ork
in p
rogr
ess-
trac
king
opp
ortu
nitie
s fo
r im
prov
emen
t an
d ho
pe t
o in
corp
orat
e ph
arm
acy
tech
s
KEY
LESS
ON
S LE
ARN
ED•
We
didn
’t ha
ve t
o w
ait
for
phys
icia
n pa
rtic
ipat
ion
to
star
t M
ultid
isci
plin
ary
roun
ding
•W
e di
dn’t
real
ize
how
com
plic
ated
it w
as ju
st
gett
ing
patie
nt f
riend
ly d
isch
arge
inst
ruct
ions
in t
he
Med
itech
disc
harg
e ro
utin
e.
•M
edic
atio
n is
a h
uge
chal
leng
e an
d op
port
unity
Per
cent
of
Pro
ject
Q
uart
erly
Tas
ks
Com
plet
ed
Q1
Task
sQ
2 Ta
sks
Q3
task
s
89%
90%
80%
RESU
LTS/
RETU
RN O
N I
NVE
STM
ENT
•M
edic
are
LOS
3.6
days
•Ca
re T
rans
ition
s &
Dis
char
ge
Sect
ions
for
HCA
PHS
tren
ding
up
•Fe
wer
LO
S ou
tlier
s fo
r ta
rget
di
agno
ses
RESU
LTS
TEAM
ACC
OM
PLIS
HM
ENTS
•Be
tter
Com
mun
icat
ion
amon
g th
e pa
tient
s, b
edsi
de n
urse
s, c
ase
man
agem
ent,
and
anc
illar
y st
aff
rega
rdin
g di
scha
rge
need
s an
d di
spos
ition
•Pa
tient
s ca
n se
e th
at w
e ar
e w
orki
ng
toge
ther
as
a te
am t
o en
sure
the
y ar
e su
cces
sful
onc
e th
ey le
ave
they
hos
pita
l
0.00
%
5.00
%
10.0
0%
15.0
0%
20.0
0%
25.0
0%
30.0
0%
AMI
Rea
dmits
CHF
Rea
dmits
Pneu
mon
ia R
eadm
itsCO
PD R
eadm
itsTo
tal h
ips/
knee
read
mits
CABG
Stro
keSe
psis
w s
econ
dary
Pneu
mon
iaH
ospi
tal W
ide
Goa
lQ
2 20
15Q
2 2
016
Goal
Q2 20
15Q2
2016
AMI Re
admits
13.75%
3.03%
11.80%
CHF R
eadmit
s17.
50%21.
13%15.
38%Pne
umoni
a Read
mits
14.90%
12.00%
11.54%
COPD
Readm
its15.
70%13.
70%13.
64%Tot
al hips
/knee
readm
its3.4
0%11.
00%5.5
6%CA
BG14.
80%25.
00%0.0
0%Str
oke9.4
0%0.0
0%4.5
5%Sep
sis w s
econda
ry Pneu
monia
17%12.
50%Ho
spital
Wide
10%9.4
1%9.1
2%
20
Merc
y Hos
pita
l Spr
ingf
ield
Impr
ovin
g Tr
ansit
ions
of C
are a
ndRe
ducin
g Ho
spita
l Rea
dmiss
ions
fo
r Tot
al Hi
p an
d Kn
ee A
rthro
plas
ty[
PROJ
ECT
GOAL
•Co
nduc
ted
real
-tim
e re
adm
issio
n pa
tient
inte
rvie
ws t
o ob
tain
the
patie
nt’s
pers
pect
ive.
•
Inst
itute
d a
stan
dard
ized
bow
el re
gim
en to
pro
activ
ely
redu
ce o
pioi
d-in
duce
d po
st-o
pera
tive
cons
tipat
ion
and
ileus
. •
Impl
emen
ted
an e
lect
roni
c sm
art p
hras
e to
pul
l the
read
miss
ion
risk
scor
e in
to p
rogr
ess n
otes
.•
Desig
ned
and
impl
emen
ted
a sm
art p
hras
e ut
ilizin
g th
e Ch
arlso
nco
mor
bidi
tysc
ore
to a
id w
ith p
reop
erat
ive
deci
sion
mak
ing.
•
Rede
signe
d th
e pr
oces
s and
freq
uenc
y of
pos
t-di
scha
rge
phon
e ca
lls.
•Im
plem
ente
d a
“hot
line”
num
ber f
or p
ost-
surg
ical
pat
ient
s to
call
rega
rdin
g an
y fo
llow
-up
need
s or c
once
rns.
•M
onth
ly d
etai
led
char
t rev
iew
of e
very
read
miss
ion
to a
sses
s tre
nds f
or
cont
ribut
ing
fact
ors a
nd o
ppor
tuni
ties f
or im
prov
emen
t.•
Mon
thly
trac
king
shee
t disp
laye
d fo
r sur
geon
s and
adv
ance
d pr
actic
e pr
ofes
siona
ls.
IDEN
TIFI
ED B
ARRI
ERS
TO P
ROJE
CT
•Di
fficu
lty c
oord
inat
ing
care
acr
oss b
oth
inpa
tient
and
out
patie
nt
spec
trum
s.
•Po
stop
erat
ive
com
mun
icat
ion
dela
ys a
nd in
cons
isten
cy.
•In
cons
isten
t med
icat
ion
reco
ncili
atio
n.
•Pe
rcep
tion
that
we
cann
ot p
reve
nt re
adm
issio
ns o
r im
pact
wha
t ha
ppen
s afte
r disc
harg
e.•
Incr
ease
d di
fficu
lty o
f im
pact
ing
deci
sions
afte
r pat
ient
arr
ival
to th
e Em
erge
ncy
Depa
rtm
ent.
THA/
TKA
MED
ICAR
E AL
L CA
USE
UNPL
ANN
ED R
EADM
ISSI
ON
RETU
RN O
N IN
VEST
MEN
T•
Inpa
tient
and
out
patie
nt m
ultid
iscip
linar
y te
am a
ppro
ach
help
ed u
s em
brac
e a
spiri
t of t
eam
wor
k.•
Patie
nts a
nd fa
mili
es w
ere
exci
ted
to b
e pa
rt o
f the
pro
cess
and
the
info
rmat
ion
obta
ined
was
an
inte
gral
par
t of o
ur im
prov
emen
t pro
cess
. •
Impr
oved
insig
ht in
to w
hy re
adm
issio
ns o
ccur
and
how
we
can
redu
ce
read
miss
ions
that
we
once
con
sider
ed im
poss
ible
to im
pact
.
KEY
LESS
ONS
LEAR
NED
TEAM
STR
UCTU
RE &
MEM
BERS
•Li
sten
to th
e vo
ices
of t
he p
atie
nt a
nd fa
mily
.•
Deve
lop
inpa
tient
and
out
patie
nt c
oalit
ions
and
par
tner
ship
s for
shar
ed
lear
ning
, bar
rier m
itiga
tion
and
shar
ing
of su
cces
ses.
•De
velo
p da
ta in
fras
truc
ture
and
ana
lytic
s for
real
-tim
e so
lutio
ns, a
nd in
a
user
-frie
ndly
form
at fo
r con
siste
nt u
se.
•A
proa
ctiv
e, c
onsis
tent
team
-bas
ed a
ppro
ach
is re
quire
d to
impa
ct
patie
nts p
rior t
o th
eir a
rriv
al to
the
Emer
genc
y De
part
men
t.
THA/
TKA
READ
MIS
SION
IMPA
CT
•Re
adm
issio
ns a
re a
bove
CM
S ex
pect
ed ra
te, r
esul
ting
in a
larg
e fin
anci
al p
enal
ty a
nd re
duce
d ho
spita
l qua
lity
ratin
g.•
Read
miss
ion
rate
neg
ativ
ely
impa
cts c
ontr
actin
g d
iscus
sions
with
in
sure
rs a
nd e
mpl
oyer
s.•
Read
miss
ions
are
also
disr
uptiv
e to
pat
ient
s and
thei
r fam
ilies
, and
re
sult
in lo
wer
satis
fact
ion
with
car
e.
•M
edic
are
all-c
ause
30
day
unpl
anne
d re
adm
issio
n ra
te
<2%
for
elec
tive
Tota
l Hip
and
Kne
e Ar
thro
plas
ty.
KEY
SOUL
UTIO
NS
IMPL
EMEN
TED
•M
ultid
iscip
linar
y te
am w
ith w
eekl
y m
eetin
gs a
nd m
onth
ly u
pdat
e to
le
ader
ship
•Ph
ysic
ian—
Hosp
italis
t, Pu
lmon
olog
ist, C
ardi
olog
ist, O
rtho
Hos
pita
list,
Inte
rnal
Med
icin
e
•Ph
arm
acy—
Inpa
tient
, Ort
ho H
ospi
tal,
Phar
mac
othe
rapy
•
Care
Man
agem
ent—
Inpa
tient
and
Am
bula
tory
•Re
spira
tory
The
rapy
•
Mer
cy M
edic
al S
uppl
y •
Mer
cy H
ome
Heal
th
•Ca
rdio
pulm
onar
y—In
patie
nt a
nd O
utpa
tient
•
Qua
lity
Reso
urce
s•
Emer
genc
y De
part
men
t & E
mer
genc
y M
edic
al S
ervi
ce•
Nur
sing
•M
arke
d an
d co
ntin
ued
redu
ctio
n in
bot
h M
edic
are
and
Ove
rall
Read
miss
ion
Rate
s.•
Incr
ease
d en
gage
men
t of s
urge
ons,
nur
sing,
adm
inist
ratio
n, a
nd
supp
ort s
taff
alig
ned
with
a c
omm
on g
oal.
•Ch
oosin
g a
defin
ed fo
cus a
nd sc
ope
allo
wed
the
team
to m
ake
rapi
d ch
ange
s in
dire
ctio
n ba
sed
on in
itial
resu
lts a
nd fe
edba
ck, a
nd w
ill
func
tion
as a
bas
is fo
r wid
er u
pcom
ing
chan
ges.
6.3%
5.7%
8.0%
2.1%
3.0%
2.5%
6.8%
2.3%
16.3
%
7.1%
5.3%
3.2%
0.0%
7.9%
2.1%
4.8%
2.0%
2.1%
3.6%
0.0%
0.0%
8.8%
7.0%
4.3%
0%10%
20%
30%
40%
50%
Aug-
14Se
p-14
Oct
-14
Nov
-14
Dec-
14Ja
n-15
Feb-
15M
ar-1
5Ap
r-15
May
-15
Jun-
15Ju
l-15
Aug-
15Se
p-15
Oct
-15
Nov
-15
Dec-
15Ja
n-16
Feb-
16M
ar-1
6Ap
r-16
May
-16
Jun-
16Ju
l-16
MER
CY H
OSPI
TAL
SPRI
NGF
IELD
•Te
rtia
ry h
ospi
tal a
nd L
evel
1 tr
aum
a ce
nter
•34
,062
acu
te d
ischa
rges
•12
,437
inpa
tient
and
25,
789
outp
atie
nt su
rger
ies
•92
,836
ED
visit
s
TEAM
ACC
OMPL
ISH
MEN
TS
SUST
AINA
BILI
TY &
SPR
EAD
•Fr
ont-
line
staf
f, ph
ysic
ians
, and
lead
ers s
hare
acc
ount
abili
ty fo
r su
cces
s.
•Co
ntin
ue st
ruct
ured
team
to fo
cus o
n im
prov
emen
t act
iviti
es a
nd
sust
ainm
ent o
f int
erve
ntio
ns.
•
Qua
lity
impr
ovem
ent t
opic
pro
min
ent d
urin
g hu
ddle
s.
•O
rgan
izatio
nal m
etric
s use
d to
trac
k im
prov
emen
ts.
•Co
ntin
ue m
onth
ly c
ase
revi
ew.
21
Mer
cy H
ospi
tal W
ashi
ngto
n R
eadm
issi
on P
roje
ctW
ashi
ngto
n, M
o. 6
3909
Co-F
acili
tato
rs:
Dr.
Kel
ly B
ain,
MD
and
Sha
ron
Hol
tmey
er, C
RT,,
RPFT
, M
BA, C
PHQ
PR
OJE
CT
FOC
US
Incr
easi
ng “
All C
ause
All
Payo
r” r
eadm
issi
on r
ates
. Le
ss t
han
50%
pat
ient
s w
ith a
rea
dmis
sion
w
ithin
30
days
did
not
hav
e a
phys
icia
n vi
sit
befo
re r
eadm
issi
onFo
cus
on t
he f
ollo
win
g di
agno
sis
popu
latio
ns:
•H
eart
Fai
lure
(H
F)•
Pneu
mon
ia (
PN)
•Ac
ute
Myo
card
ial I
nfar
ctio
n (A
MI)
INIT
IAL
PR
OJE
CT
BA
RR
IER
S ID
ENTI
FIED
Acqu
isiti
on o
f tim
ely
data
fro
m h
ospi
tal d
atab
ases
Lack
of
patie
nts
abili
ty t
o id
entif
y re
ason
s fo
r re
adm
issi
onLa
ck o
f in
put
from
fam
ily a
nd/o
r co
mm
unity
mem
bers
as
to
reas
ons
for
read
mis
sion
Lim
ited
feed
back
fro
m p
ost-
hosp
ital h
ome
heal
th
care
give
rs a
s to
rea
sons
for
pat
ient
re
adm
issi
onN
o av
aila
ble
appo
intm
ent
slot
s in
pro
vide
r sc
hedu
le f
or
post
acu
te c
are
visi
ts
KEY
SO
LUTI
ON
S IM
PLE
MEN
TED
Mul
ti-di
scip
linar
y te
am d
evel
oped
-Inc
ludi
ng h
omec
are,
O
PT C
are
Man
agem
ent
& c
omm
unity
mem
ber
Dev
elop
ed T
eam
Cha
rter
and
Str
uctu
reD
eter
min
ed h
igh
risk
popu
latio
n th
at p
rese
nts
with
a
read
mis
sion
sco
re o
f >
8 ba
sed
on M
ercy
cr
iteria
Impl
emen
ted
Care
Man
agem
ent
sche
dulin
g ph
ysic
ian
appo
intm
ents
for
hig
h ris
k pa
tient
s vi
a EH
RIn
terv
iew
ed r
eadm
itted
pat
ient
s to
iden
tify
barr
iers
to
succ
essf
ul d
isch
arge
Colla
bora
tion
with
Com
plex
Car
e Te
am
KEY
LES
SON
S LE
AR
NED
Mul
tidis
cipl
inar
y Re
adm
issi
on T
eam
-Phy
sici
an le
d an
d in
clud
es I
npat
ient
and
Out
patie
nt t
eam
m
embe
rs
RET
UR
N O
N I
NV
ESTM
ENT
RES
ULT
S
TEA
M A
CC
OM
PLI
SHM
ENTS
Com
plex
Car
e Te
amTe
am d
evel
oped
fro
m n
eed
iden
tifie
d by
rea
dmis
sion
team
Look
s at
mos
t co
mpl
icat
ed p
atie
nts
who
hav
e ch
alle
nges
st
ayin
g ho
me
Dev
elop
ed s
trat
egy
of c
are
note
-Writ
ten
by p
hysi
cian
to
help
dire
ct c
are
to a
void
rea
dmis
sion
if p
ossi
ble
>55
% M
edic
are
patie
nts
have
an
appo
intm
ent
with
ph
ysic
ian
sche
dule
d pr
ior
to d
isch
arge
0.00
%
10.0
0%
20.0
0%
30.0
0%
40.0
0%
50.0
0%
60.0
0%
70.0
0%
80.0
0%
FFY
2015
FFY
2016
FFY2
017
72.0
0%
23.0
0%
0
Percent
MH
W %
Rea
dmis
sion
Pen
alty
$0
$20,
000
$40,
000
$60,
000
$80,
000
$100
,000
$120
,000
$140
,000
FFY
2015
FFY
2016
FFY2
017
-$13
2,28
4
-$37
,639
$0
Dollars
MH
W R
eadm
issi
on P
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ty D
olla
rsD
aily
cha
rt r
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ws
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ided
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nfor
mat
ion
Care
Man
agem
ent
sche
dulin
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tmen
ts
prio
r to
dis
char
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succ
essf
ulVa
lidat
ed n
eed
for
Com
plex
Car
e Te
amCa
re M
anag
er a
dded
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team
foc
us in
ED
Lear
ned
Care
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rven
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arlie
r ra
ther
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ter
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atie
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tay
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emen
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rvie
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dmitt
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embe
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rge
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ruct
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Firs
t qu
arte
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ompl
etio
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rter
tas
k co
mpl
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%Th
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ask
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plet
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s Ta
sks-
67%
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ject
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rter
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asks
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ompl
eted
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ISSI
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M
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se A
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ayor
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ate
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ate
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All
Pay
or P
N R
ate
PN R
ate
Mon
ey S
aved
Dec
reas
ed r
eadm
issi
on p
enal
ty f
rom
~$1
32K
to $
0 w
ithin
3 y
ears
Tim
e Sa
ved
Dai
ly m
ultid
isci
plin
ary
disc
usse
s pl
anni
ng d
isch
arge
s an
d pr
epar
e pa
tient
s fo
r su
cces
sful
dis
char
ge p
lan
Stra
tegy
of
Care
LOS
not
nega
tivel
y im
pact
edSa
ving
s re
late
d to
Out
com
esIm
prov
ed p
roce
sses
dec
reas
ed p
enal
ty f
or r
eadm
issi
on79
% o
f el
igib
le d
isch
arge
s le
ave
hosp
ital w
ith a
sch
edul
ed a
ppoi
ntm
ent
with
PCP
with
in o
ne w
eek
22
Imm
ersi
on P
ilot P
roje
ct: R
eadm
issi
on R
educ
tion
KEY
SOLU
TION
S IM
PLEM
ENTE
D•
Alth
ough
we
wer
e cu
rren
tly p
artic
ipat
ing
in
mul
ti-di
scip
linar
y da
ily ro
unds
this
proj
ect
prov
ided
us a
n op
port
unity
to re
view
our
pr
oces
s, c
ompa
red
to b
est p
ract
ice.
•
Addi
tiona
lly w
e fo
und
that
incr
easin
g ou
r pos
t di
scha
rge
inte
rven
tions
incl
udin
g ca
re a
t hom
e an
d ho
me-
heal
th w
as v
ital t
o pa
tient
succ
ess.
SUST
AINA
BILI
TY A
ND
SPRE
AD
BIGG
EST
ACCO
MPL
ISH
MEN
T •
One
of o
ur b
igge
st a
ccom
plish
men
ts is
the
qual
ity d
evel
opm
ent o
f a m
ultid
iscip
linar
y te
am
that
dai
ly e
ngag
es w
ith o
ur p
atie
nts a
nd th
eir
fam
ily to
disc
uss d
ischa
rge
plan
ning
and
ed
ucat
ion.
•
This
team
has
bec
ome
mor
e co
hesiv
e an
d is
now
bet
ter e
quip
ped
to a
ssist
our
pat
ient
s.
TASK
S %
COM
PLET
ION
•
100%
1st
Qua
rter
•10
0% 2
ndQ
uart
er•
100%
3rd
Qua
rter
COST
SAV
INGS
W
ith 5
mon
ths w
ith ze
ro in
patie
nt to
inpa
tient
in
tern
al re
adm
issio
ns w
e ce
lebr
ate
appr
opria
te
disc
harg
e pr
epar
atio
n an
d qu
ality
disc
harg
e pl
anni
ng.
BIGG
EST
LESS
ONS
LEAR
NED
HOS
PITA
L IN
FORM
ATIO
N
•Cr
itica
l Acc
ess H
ospi
tal l
ocat
ed in
Rur
al N
W
Miss
ouri
•M
embe
r of t
he
Mos
aic
Syst
em•
Inno
vativ
e Q
ualit
y Fo
cus
•Cr
eativ
e So
lutio
ns c
an a
lso b
e Si
mpl
e So
lutio
ns•
Early
in th
e pr
ojec
t we
foun
d ou
rsel
ves o
ften
sayi
ng, “
We
can’
t” o
r offe
ring
excu
ses.
W
e qu
ickl
y ch
ange
d th
at to
“W
hy n
ot?”
thi
s un
leas
hed
the
team
to se
ek c
reat
ive
and
simpl
e so
lutio
ns•
Any
plan
that
doe
s not
incl
ude
the
patie
nt w
ill
fail •Th
is di
scov
er m
oved
our
mul
tidisc
roun
ding
(c
onsis
ting
of 1
0 di
scip
lines
) to
the
beds
ide.
Our
wor
k w
ith re
adm
issio
ns w
ill li
kely
not
end
in
the
fore
seea
ble
futu
re.
We
will
con
tinue
to
enga
ge w
ith c
reat
ive
solu
tions
to b
ette
r car
e fo
r ou
r pat
ient
s, fa
mili
es a
nd n
eigh
bors
. O
ur re
solv
e in
onl
y st
reng
then
ed b
y ou
r con
tinuo
us
rem
inde
rs th
at w
e ar
e al
way
s car
ing
for
som
eone
’s fa
mily
, pot
entia
lly o
ur o
wn.
•Th
is te
am p
lans
to c
ontin
ue to
wor
k to
impr
ove
our d
ischa
rge
proc
ess a
s wel
l as i
ncre
asin
g po
st
disc
harg
e se
rvic
es.
•W
e ha
ve a
lso b
egan
to lo
ok a
t int
erve
ntio
ns fo
r pa
tient
s who
are
at r
isk p
rior t
o th
e in
dex
adm
issio
ns in
clud
ing
med
icat
ion
assis
tanc
e an
d ch
roni
c di
seas
e m
anag
emen
t sup
port
gro
ups.
NEX
T ST
EPS/
FUTU
RE P
LAN
S
RESU
LTS
BARR
IERS
•Di
fficu
lt da
ta m
inin
g fr
om E
HR•
Bein
g CA
H in
crea
ses o
ur ri
sk fo
r a h
igh
seco
nd
stay
leak
age
rate
•Ra
tione
d St
aff R
esou
rces
PROJ
ECT
FOCU
SW
e se
t out
to d
ecre
ase
all c
ause
, 30
Day
inpa
tient
re
adm
issio
ns to
our
hos
pita
l with
in th
e de
fined
pr
ojec
t tim
efra
me.
23
Sout
heas
t H
ospi
tal R
eadm
issi
on R
educ
tion
Pro
gram
Cape
Gira
rdea
u, M
O 6
3701
26
9 Be
d-N
on p
rofit
org
aniz
atio
nTE
AM M
EMBE
RS:
To
nya
Mey
er –
Pro
ject
Lea
dR
ich
ard
Cro
wle
y-Fa
cilit
ator
Jan
Rig
don
-Ex
ecut
ive
Cha
mpi
onM
yrna
War
d-P
roje
ct C
ham
pion
Lo
ri M
errit
t-ED
Julie
Met
zger
-Cas
e M
anag
emen
tKa
y Li
twic
ki-R
DLD
Valo
rie R
hode
s-SP
CU N
urse
Man
ager
Deb
bie
Hof
fman
-Med
tele
Nur
se M
gr.
Kelly
Urh
ahn-
Resp
irato
ry T
hera
pyM
ary
Beth
Cor
gan-
HF
APRN
Anita
Sm
ith-C
ardi
ac P
ulm
onar
y Re
hab
Nur
se M
gr.
Blak
e U
rhah
n-Ph
arm
DPa
ulin
e Ar
nold
-Exe
c. D
ir. o
f Q
ualit
y L
alita
Toe
nisk
oett
er-C
ase
Man
agem
ent
A
man
da G
ravi
ett-
Adm
inis
trat
ive
Assi
stan
t
PRO
JECT
FO
CUS
•To
dec
reas
e al
l cau
se r
eadm
issi
ons
(inpa
tient
s re
turn
ing
as a
n ac
ute
care
in
patie
nt t
o th
e fa
cilit
y w
ithin
30
days
of
disc
harg
e –a
ges
18 a
nd o
ver
for
all
payo
rs)
from
a b
asel
ine
of 1
0.69
% t
o 9.
62%
.
INIT
IAL
PRO
JECT
BAR
RIER
S ID
ENTI
FIED
•H
igh
dise
ase
spec
ific
read
mis
sion
rat
es•
The
lack
of
repo
rt a
vaila
bilit
y fo
r re
al t
ime
inte
rnal
dat
a to
tr
ack
dise
ase
spec
ific
read
mis
sion
s•
Case
man
ager
s w
ere
look
ing
at r
eadm
issi
ons
daily
but
did
no
t ha
ve t
he t
ools
nec
essa
ry t
o dr
ive
chan
ge
KEY
SOLU
TIO
NS
IMPL
EMEN
TED
•Co
llabo
ratio
n w
ith I
T in
the
dev
elop
men
t of
inte
rnal
rea
dmis
sion
rep
orts
for
dai
ly
revi
ew•
Dev
elop
men
t an
d im
plem
enta
tion
of a
n el
ectr
onic
rea
dmis
sion
ris
k as
sess
men
t•
Dev
elop
men
t an
d im
plem
enta
tion
of a
n el
ectr
onic
pat
ient
rea
dmis
sion
inte
rvie
w
tool
•D
evel
opm
ent
and
use
of a
com
plex
car
e te
am r
evie
w•
Impl
emen
tatio
n of
a p
allia
tive
care
con
sult
prog
ram
•Im
prov
ed n
otifi
catio
ns fo
r m
ultid
isci
plin
ary
scre
enin
g re
ferr
als
KEY
LESS
ON
S LE
ARN
ED•
Tool
s ar
e us
eful
but
with
out
inte
rven
tions
the
rea
dmis
sion
ris
k sc
ore
mea
ns n
othi
ng•
Hav
ing
inte
rven
tions
in p
lace
isn’
t en
ough
-the
re m
ust
be a
war
enes
s,
unde
rsta
ndin
g an
d bu
y in
fro
m
phys
icia
ns a
nd t
he m
ultid
isci
plin
ary
care
tea
m
Per
cent
of
Pro
ject
Q
uart
erly
Tas
ks
Com
plet
ed
1stQ
uart
er2n
dQ
uart
er3r
dQ
uart
er
Read
mis
sion
s10
0%85
%69
%
RESU
LTS:
201
5 BA
SELI
NE
VS20
16 Y
TDTH
RU A
UG
UST
•Al
l Cau
se R
eadm
issi
on R
ate
Redu
ced
By 4
5.25
%
(10.
69%
to
5.85
%)
•Pn
eum
onia
Rea
dmis
sion
Rat
e Re
duce
d By
50.
63%
(1
5.58
% t
o 7.
69%
)•
Hea
rt F
ailu
re R
eadm
issi
on R
ate
Redu
ced
By 3
3.33
%
(20.
0% t
o 13
.33%
)•
COPD
Read
mis
sion
Rat
e Re
duce
d By
68.
93%
(1
8.71
% t
o 5.
81%
)
RESU
LTS
10.7
3%
6.96
%
3.81
%
9.84
%
4.83
%
3.09
%
4.59
%
3.28
%
0%2%4%6%8%10%
12%
Jan
Feb
Mar
Apr
May
Jun
Jul
Au
gSe
pO
ctN
ovD
ec
Readmission Rate
All
Cau
se R
eadm
issi
on R
ate
-20
16
22.2
2%
50.0
0%
3.70
%
10.5
3%
0.00
%0.
00%
8.33
%
43.7
5%
9.09
%
13.3
3%
8.33
%
0.00
%
10.0
0%
21.4
3%
13.3
3%
23.0
8%
5.56
%6.
25%
5.80
%
0.00
%0.
00%
33.3
3%
0.00
%0%10
%
20%
30%
40%
50%
60%
Jan
Feb
Mar
Apr
May
Jun
Jul
Au
gSe
pO
ctN
ovD
ec
Readmission Rate
Dis
ease
Spe
cifi
c R
eadm
issi
on R
ate
-20
16
Pne
umon
iaH
eart
Fai
lure
CO
PD
TEAM
ACC
OM
PLIS
HM
ENTS
•D
ecre
ased
the
all
caus
e re
adm
issi
on t
o sa
me
faci
lity
by 4
5.25
%•
Dev
elop
ed m
ultip
le r
eadm
issi
on t
ools
•Be
gan
deve
lopi
ng c
olla
bora
tion
betw
een
SNFs
on
read
mis
sion
s
Read
mis
sion
s Pe
rfor
man
ce I
mpr
ovem
ent
Team
Not
Pic
ture
d: L
ori M
errit
t, D
ebbi
e H
offm
an, K
elly
Urh
ahn,
Pau
line
Arno
ld, A
nita
Sm
ith, V
alor
ie
Rhod
es
24
Imm
ersi
on P
ilot P
roje
ct: R
EAD
MIS
SIO
NS
[
KEY
SOLU
TION
S IM
PLEM
ENTE
D•
Deve
lope
d a
proc
ess i
mpr
ovem
ent t
eam
•In
itiat
ed a
Hig
h Ri
sk S
cree
ning
tool
in o
ur E
MR
to id
entif
y th
ose
who
are
at
hig
h ris
k fo
r rea
dmiss
ion
and
post
ed o
n th
e st
atus
boa
rd.
•Cr
eate
d co
nsist
ent c
hron
ic d
iseas
e ed
ucat
ion
acro
ss a
ll le
vels
of c
are
•Im
plem
ente
d a
daily
mul
tidisc
iplin
ary
patie
nt c
are
team
hud
dle
•Fo
cuse
d on
Pha
rmac
y ed
ucat
ion
for a
ll hi
gh ri
sk a
nd re
adm
it pa
tient
s•
Re-la
unch
ing
of st
aff e
duca
tion
on Te
ach-
back
•Ac
cura
te a
nd a
cces
sible
disc
harg
e m
edic
atio
n lis
ts a
nd m
edic
atio
n sa
fety
focu
s at a
ll le
vels
•Co
ordi
nate
d ac
cura
te m
edic
atio
n re
conc
iliat
ion
at a
dmiss
ion,
at a
ny
chan
ge in
the
leve
l of c
are
and
at d
ischa
rge
•Im
plem
ente
d po
st d
ischa
rge
phon
e ca
lls w
ithin
2 d
ays a
nd fo
llow
up
appo
intm
ents
with
in 3
-5 d
ays o
f disc
harg
e•
Deve
lope
d a
new
disc
harg
e pr
oces
s i.e
. Sm
art D
ischa
rge
•Re
adm
issio
n Co
ncur
rent
Rev
iew
s (RA
T te
am)-d
iscus
s pat
ient
s co
ncur
rent
ly
IDEN
TIFI
ED B
ARRI
ERS
TO P
ROJE
CT
SUCC
ESS
BIGG
EST
ACCO
MPL
ISH
MEN
T
•Im
plem
enta
tion
of H
igh
Risk
Scr
eeni
ng to
ol•
Fost
er g
ood
com
mun
icat
ion
betw
een
the
Intr
a-di
scip
linar
y te
am•
Med
icat
ion
Reco
ncili
atio
n•
Phar
mac
ist e
duca
ting
poly
-pha
rmac
y an
d hi
gh ri
sk p
atie
nts
•Te
ach-
back
•Fo
llow
up
phon
e ca
lls
TASK
S %
COM
PLET
ION
•1st
Qua
rter
Tas
ks C
ompl
etio
n 10
0%•
2ndQ
uart
er T
asks
Com
plet
ion
100%
•3rd
Qua
rter
Tas
ks C
ompl
etio
n 10
0%
Char
ts COST
SAV
INGS
BIGG
EST
LESS
ONS
LEAR
NED
Serie
s 1, 4
.5
Serie
s 2, 2
.8
Serie
s 3, 5
0123456
Cate
gory
1Ca
tego
ry 2
Cate
gory
3Ca
tego
ry 4
Axis Title
Char
t Titl
e
TEAM
MEM
BERS
•En
gage
you
r disc
harg
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nclu
ding
nur
sing
hom
es) f
rom
th
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ginn
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rify
adm
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ratio
n su
ppor
t and
invo
lvem
ent t
o en
dors
e ch
ange
. Eng
age
your
fron
t lin
e le
ader
s. E
ffect
ive
chan
ge
requ
ires a
team
!•
The
need
for o
ngoi
ng re
-edu
catio
n w
as n
eces
sary
to su
stai
n pr
ogre
ss.
•Th
ere
are
limita
tions
to E
MR
adap
tabi
lity
and
repo
rtin
g•
Conf
lictin
g pr
iorit
ies a
re a
cha
lleng
e an
d im
pact
ing
initi
al b
uy-
in, c
linic
al st
aff’s
ava
ilabi
lity
and
sche
dulin
g, a
nd th
e ov
eral
l en
gage
men
t of o
ur te
am
Pa
tient
and
fam
ily e
ngag
emen
t
EM
R lim
itatio
ns
M
ulti-
disc
iplin
ary
team
aw
aren
ess
Ex
tern
al st
ake
hold
er in
volv
emen
t
Co
mm
unic
atio
n iss
ues-
acro
ss a
ll le
vels
of c
are
Bran
die-
Soci
al S
ervi
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Mis
sy-Q
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ctor
Laur
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arm
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la-IS
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Man
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irect
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sy-R
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nice
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Hudd
le B
oard
-
Patie
nt N
ame
& D
x-
Prim
ary
Care
give
r Nam
e-
VTE
(red
mag
net)
-Fa
ll ris
k (y
ello
w m
agne
t)-
Spec
ialty
Con
sults
-Pl
an o
f Car
e-
30 d
ay re
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it (s
ad fa
ce m
agne
t)
and
nam
e in
RED
-Re
d He
arts
for C
HF e
duca
tion
pa
cket
s
25
Fall
Red
ucti
on a
t St
. Luk
e’s
Reh
abili
tati
on H
ospi
tal
Team
Mem
bers
: R
obby
n R
oth
DQ
M, C
hris
Bae
chle
CEO
, Bet
h C
lam
p C
CO
, Jes
sica
Cap
pa D
RS,
Jef
f R
itte
r D
OP
, Cat
hy F
emm
er N
urse
Edu
cato
r, T
amm
y M
arkh
am I
RF -
PA
I C
oord
inat
or
PRO
JECT
FO
CUS
Red
uce
falls
wit
h an
d w
itho
ut in
jury
40
% b
y D
ecem
ber
2016
.
INIT
IAL
PRO
JECT
BAR
RIER
S ID
ENTI
FIED
1.U
tiliz
ing
Qua
laris
for
pro
cess
aud
its.
2.Co
mpl
etin
g pr
oces
s au
dits
.
KEY
SOLU
TIO
NS
IMPL
EMEN
TED
1.Ch
ange
d to
MO
RSE
Fall
Scal
e.2.
Enfo
rce
clin
ical
sta
ff s
tayi
ng w
ith h
igh
risk
fall
patie
nts
whi
le in
bat
hroo
m.
3.Re
vise
d f
all h
uddl
e fo
rm f
or d
ata
colle
ctio
n.4.
Bega
n “E
yes
on Y
ou”
prog
ram
for
hig
h fa
ll ris
k pa
tient
s.5.
Prov
ide
larg
er b
right
yel
low
roo
m s
igna
ge
to r
emin
d pa
tient
to
call
for
assi
stan
ce.
6.Cl
inic
al li
aiso
ns t
o in
clud
e hi
stor
y,
freq
uenc
y of
fal
ls a
nd M
ORS
E fa
ll sc
ore
on
the
Pre-
adm
issi
on s
cree
n to
fac
ilita
te
appr
opria
te r
oom
pla
cem
ent.
7.
Cons
ider
sitt
er if
pat
ient
fal
ls t
wo
times
.8.
Re-e
duca
te s
taff
on
purp
osef
ul r
ound
ing;
nu
rsin
g su
perv
isor
s au
dit
staf
f ro
undi
ng.
9.O
rder
and
impl
emen
ted
a ne
w a
larm
de
vice
s f
or e
very
pat
ient
roo
m.
10.
Nur
sing
Sup
ervi
sor
assi
gns
patie
nt r
oom
pe
r cl
inic
al p
rese
ntat
ion/
safe
ty n
eeds
.11
.Fa
ll po
licy
revi
sed
for
low
and
hig
h ris
k in
terv
entio
ns.
12.
Adde
d fa
ll in
terv
entio
ns t
o PR
O-D
OC;
di
scus
s at
tea
m c
onfe
renc
e.
KEY
LESS
ON
S LE
ARN
ED1.
Early
iden
tific
atio
n pr
ior
to a
dmis
sion
al
low
s fo
r ap
prop
riate
roo
m p
lace
men
t.2.
Plac
ing
alar
m u
nits
in e
very
roo
m f
or
imm
edia
te a
cces
s by
sta
ff.
3.Po
st a
ctio
n pl
an f
or s
taff
aw
aren
ess.
4.U
tiliz
e LE
AN b
oard
.5.
Invo
lve
staf
f in
fal
l com
mitt
ee m
eetin
gs.
6.D
iscu
ss fa
ll ou
tcom
es a
t te
am m
eetin
gs.
Per
cent
of
Pro
ject
Q
uart
erly
Ta
sks
Com
plet
ed
Qua
rter
1Q
uart
er2
Qua
rter
3
90%
90%
50%
RESU
LTS
TEAM
ACC
OM
PLIS
HM
ENTS
1. F
ull s
cale
FM
ECA
on F
alls
.2.
“Ey
es o
n Yo
u” p
rogr
am f
or h
igh
risk
fall
patie
nts.
3. A
larm
and
com
pone
nts
in e
very
pat
ient
roo
m.
Plea
se n
ote t
hat c
ompe
ndiu
m co
nten
t is d
eriv
ed fr
om h
ospi
tal a
pplic
atio
ns.
