Eliminate VAP Coaching Call

1. Eliminate VAP Coaching Call February 7, 2013

2. Objectives • Share Daily Rounding Data Collection Process Methods • Introduce Process Mapping • Highlight Next Steps

3. Group Discussion • When PEEP and Fi02 are measured • Who documents it? • Where is it documented? • For other process measures, e.g., HOB => 30 degrees, use of oral care, etc. • Who documents it? • Where is it documented? • Who enters the data into the Patient Safety and Quality portal? • How do you manage coverage of these activities on off-shifts, weekends, holidays and vacations? • How do you know if your process is working? • Who is responsible for training the data collectors?

4. Process Mapping

5. Process Map • Process maps (also known as process diagrams or flowcharts) allow teams to • Visualize a process • Identify the actual flow or sequence of events in a process • Identify problem areas and unnecessary steps • Come to agreement on the steps of the process • Examine which activities may impact the process performance • Compare and contrast actual versus ideal flow to identify improvement opportunities and maximize efficiency

6. Creating a Process Map • Determine the boundaries of the process • Clearly define where the process starts (input) and ends (final output) • Determine the steps in the process • Brainstorm a list of all major activities, inputs, outputs, transfers, handovers and decisions from the beginning of the process to the end

7. Creating a Process Map • Sequence the steps • Arrange the steps in the order they are carried out. • Sequence what is, not what should be. • Don’t draw in the arrows yet. • HAVE FUN! Consider using Post-It® Notes so you can move steps

8. Creating a Process Map • Draw the process map • Label each step in a way that is understandable to everyone. • Document who carries out the step. • Add arrows to show the direction of the flow of each step in the process.

9. Creating a Process Map • Test the process map • Validate the map. • Follow the people who carry out the process and adjust the map as needed to reflect the current process.

10. Creating a Process Map • Finalize the process map • Is this process being run the way it should be? • Are people following the process as charted? • Are there obvious complexities or redundancies that can be reduced or eliminated? • How different is the current process from an ideal one? • Draw an ideal Flowchart. Compare the two (current versus ideal) to identify discrepancies and opportunities for improvements.

11. Considerations • Minimize the potential for staff burnout by distributing responsibilities among many. • Identify which steps can be carried out by non-clinical staff and delegate accordingly. • Think about how can you tweak the environment (i.e., the systems) to better support the process and minimize the likelihood for “cutting corners.” • How will you know if your process is working as designed?

12. Take our Pit Stop challenge! • Create a map or flowchart documenting your current processes for daily rounding data collection – weekdays and weekends.

14. Next Steps • Daily Rounding Data Collection • Continue to collect. • Submit data to Patient Safety and Quality portal https://armstrongresearch.hopkinsmedicine.org/Default.aspx • VAE Collection • Continue to collect. • Submit January data into NHSN when module becomes available (expected mid February) • Participate in Quarterly Interview • Accessing the Social Networking Site • Instructions available at: http://www.mhaonline.org/File%20Library/Quality/Eliminate%20Ventilator-Associated%20Pneumonia/Connecting-to-the-Social-Networking-Site.pdf • Hospital Survey on Patient Safety Culture (HSOPS) • Prepare to conduct survey. • If conducted in the last 12 months, results can be uploaded to the Patient Safety and Quality portal

15. Next Webinar • February 14 Content Call at 2:00 PM • Audio: 800-779-9891 • Pass code: 4757941 • Web link: https://connect.johnshopkins.edu/cuspevap/

16. Questions? • Maryland Participants • Karol G. Wicker, MHS • Phone 410-540-5056 • kwicker@mhaonline.org • Pennsylvania Participants • Mary Catanzaro, RN BSMT CIC • Phone 717-756-3958 • mcatanzaro@haponline.org