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Cohort 1 Coaching Call. March 5 2014 Facilitators: Lisa Carhuff Kathy McGowan Joyce Reid. WELCOME and Introductions. Sense of Urgency. Some is not a number; soon is not a time. Don Berwick – 100Klives Campaign. Key Concepts. Culture of Safety Promoted from the Top

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Cohort 1 coaching call

Cohort 1 Coaching Call

March 5 2014


Lisa Carhuff

Kathy McGowan

Joyce Reid

Sense of urgency
Sense of Urgency

Some is not a number;

soon is not a time.

Don Berwick – 100Klives Campaign

Key concepts
Key Concepts

Culture of Safety Promoted from the Top

Ownership at Point of Care

Engaging patients in redesign

The cohort challenge march to the goal keeping the beat
The Cohort ChallengeMarch to the Goal – Keeping the Beat

  • Topics CAUTI and Falls without Injury

  • Rapid Cycle Improvement

  • Participation guidelines

  • Baseline Data

Best practices cauti
Best Practices: CAUTI

  • Insert catheters only for appropriate indications using evidence based criteria including in the OR and ED.

  • Daily assessment of catheter necessity and meeting criteria included in bedside report

  • Leave catheters in place only as long as needed. Use nurse driven protocols for catheter removal

  • Facilitation of nurse/patient/family communication during report, rounding and interactions

  • Increase communication with nurse and physicians related to catheter continuation

  • Automatic removal orders after surgery

  • Ensure that only properly trained persons insert and maintain catheters. Perform staff competency assessment related to urinary catheter insertion and maintenance

  • Insert catheters using aseptic technique and sterile equipment (acute care setting)

  • Maintain a closed drainage system

  • Maintain unobstructed urine flow

  • Perform proper hand hygiene and use Standard (or appropriate isolation) Precautions

Sharing best practices cauti
Sharing Best Practices: CAUTI

Jane Chesser, RN, CIC Infection Control Director

Memorial Hospital and Manor

Falls with injury definition clarification
Falls with Injury: Definition Clarification

Clarification NDNQI Falls definition

Injury Level        When the initial fall report is written by the nursing staff, the extent of injury may not yet be known. Hospitals have 24 hours to determine the injury level, e.g., when you are awaiting diagnostic test results or consultation reports.

This is a required data element and you should report Falls with Injury through NOVI monthly based on the following guidelines:

  • None—patient had no injuries (no signs or symptoms) resulting from the fall; if an x-ray, CT scan or other post fall evaluation results in a finding of no injury

  • Minor—resulted in application of a dressing, ice, cleaning of a wound, limb elevation, topical medication, pain, bruise or abrasion

  • Moderate—resulted in suturing, application of steri-strips/skin glue, splinting, or muscle/joint strain

  • Major—resulted in surgery, casting, traction, required consultation for neurological (basilar skull fracture, small subdural hematoma) or internal injury (rib fracture, small liver laceration) or patients with any type of fracture regardless of treatment or patients who have coagulopathy who receive blood products as a result of a fall

  • Death—the patient died as a result of injuries sustained from the fall (not from physiologic events causing the fall)

Sharing best practices fall prevention
Sharing Best Practices: Fall Prevention

Selina Baskins, RN

Quality Coordinator

Northridge Medical Center

Sharing best practices fall prevention1
Sharing Best Practices: Fall Prevention

Erica Fishell

Sylvan Grove

Team innovations in professional practice award 2014
Team Innovations in Professional Practice Award2014

Recognizing Excellence in Improving Patient Safety and Quality

Purpose: To recognize front line staff teams who have improved safe patient care and reduced harm through innovation and operationalization of practices, processes and through collaboration with multidisciplinary teams.

Goal: To promote front line staff engagement and leadership in patient safety and quality improvements to move to zero harm through collaboration with multidisciplinary teams in a rapid cycle.

Eligibility: Multidisciplinary hospital teams, led by front line staff, who has achieved an innovation in process/practice improvement that has led to significant reduction in Safety Across the Board or increased engagement of patients/family in care.  

Application due: April 21, 2014 by noon

Data submission march 15
Data Submission – March 15:

NOVI Survey

  • INR

  • Falls with injury

  • Glycemic Control

  • Opioids NEW!!

  • EED if applicable

  • Infection (if not submitting via NHSN)



Complete the evaluation for today’s Cohort 1 Coaching Call!

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