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Organizational Accountability. Creating and Sustaining the Culture of Change Darla Belt, RN. Just the Facts. The IOM estimates that as many as 98,000 people die each year in US hospitals due to medical injuries.

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Organizational accountability

Organizational Accountability

Creating and Sustaining the Culture of Change

Darla Belt, RN

Just the facts
Just the Facts

  • The IOM estimates that as many as 98,000 people die each year in US hospitals due to medical injuries.

  • The Centers for Disease Control and Prevention estimate that two million patients suffer hospital-acquired infections each year. 

The facts cont
The Facts Cont.

  • The US spends the most money on health care of all (advanced) industrialized nations [1], but it performs more poorly than most on many measures of health care quality [2].

    [1] Reinhardt UE, Hussey PS, Anderson GF. US health care spending in an international context. Health Affairs. 2004;23(3):10-25.

    [2] Blendon RJ, Schoen C, DesRoches CM, Osborn R, Zapert K, Raleigh E. Confronting competing demands to improve quality: A five-country hospital survey. Health Affairs. 2004;23(3):119-135.

The metrics
The Metrics

  • Goal – Lives Saved: Number of staffed beds divided by 4

    • Rationale: 1 life per 4 beds should be saved

    • Example: 600 staffed beds/4 = 150 lives saved


  • Deploy Rapid Response Teams…at the first sign of patient decline

  • Deliver Reliable, Evidence-Based Care

  • Prevent Adverse Drug Events (ADEs)…by implementing medication reconciliation

  • Prevent Hospital Acquired Infections…by implementing a series of interdependent, scientifically grounded steps called “Bundles”

  • Prevent Surgical Site Infections…by reliably delivering the correct perioperative care

  • Physician Accountability…The role of today’s Medical Executive Committee

Medical response team
Medical Response Team

  • Staff member is worried about the patient

  • Acute change in heart rate

  • Acute change in systolic BP

  • Acute change in respiratory rate

  • Acute change in O2 saturation

  • Acute change in level of consciousness

Dedicated Number

Dedicated Staff


  • A bundle is just that, a bundle or grouping of best practices that have been individually proven to improve quality in an area.

  • Evidence-based protocols and practices that have been tried and tested to improve outcomes. Not theory.

Central line bundle
Central Line Bundle

  • MD and all staff assisting with insertion must disinfect hands before procedure.

  • MD must wear mask, sterile gown, sterile gloves and cap.

  • All personnel assisting with procedure must wear gloves and mask. Patient should also don mask.

  • Prep site with Chlorahex prep stick.

  • Drape site with sterile drape.

  • Dress site immediately with CVC sterile dressing kit and apply bio-patch medicated disc to site.

Ventilator bundle
Ventilator Bundle

  • HOB 30 Degrees

  • PUD Prophylaxis

  • DVT Prophylaxis

  • Mouth care Q2H

  • Sedation Vacation Q24H

  • Is patient ready to wean?

Urinary tract infection bundle
Urinary Tract Infection Bundle

  • Can urinary catheter be removed?

  • Change out catheter if pt having symptoms, insert silver coated catheter

  • Drainage bag must be kept lower than pt’s bladder at all times

  • All urinary catheters must be secured to decrease movement of catheter

  • Strict hand washing

  • Peri-care daily and after each bowel movement

Nosocomial infection rates fiscal year 2001 fiscal year 2006
Nosocomial Infection RatesFiscal Year 2001-Fiscal Year 2006

3 VAP’s in 24 Months

1 Symptomatic UTI in 24 months

Improving ami care
Improving AMI Care

  • Crucial Care – Concept of using multidisciplinary rounding and concurrent data collection to facilitate compliance with core measures, spread bundles, and improve patient outcomes.

Role of the crucial care medical directors
Role of the Crucial Care Medical Directors

  • Daily multidisciplinary rounds

  • Protocol maintenance

  • “Bundles Compliance” (Spread)

  • Staff education

  • Physician communication

    We had 21 physicians signed up to do two week rotations in this role!

Crucial care team
Crucial Care Team

  • Rotating Medical Director

  • Charge Nurse

  • Patient’s Nurse

  • Case Manager

  • Pharm D

  • Social Worker

  • Dietician

  • Core Measure Data Collectors

  • Nurse Educator

Sip and scip

  • Procedure based protocols and standing order sets

  • Assigning bottom line accountability

  • Automatic stop orders

  • Differentiating between prophylaxis and treatment

Medical staff compliance
Medical Staff Compliance

  • Protocols are “opt out” vs. “opt in”

  • Variation among populations is discouraged

  • Compliance is enforced

    • Protocol noncompliance without documented, approved rationale is subject to the disciplinary process

Disciplinary process
Disciplinary Process

  • Protocol variances should be considered an unusual occurrence

  • Three instances of protocol noncompliance generates mandatory referral to MEC

  • MEC orders focus chart review

  • Further infraction results in 14 day suspension of privileges

Lessons learned
Lessons Learned

  • Board Support

  • Senior Leader visibility

  • Create a culture where rapid cycle change is the norm

  • Disseminate the information

  • Execution is Everything

  • Celebrate your success

Words to live by
Words to Live By

“A Quality Leader’s job is never done until the Medical Staff and the Line Staff can stand up and speak for organizational quality with the same effectiveness that you can.”