Transforming Care at the Bedside across Wisconsin

1. Transforming Care at the Bedsideacross Wisconsin Monthly Webinar for February Reducing Hospital Acquired Conditions Please mute or phone by using *6. Un-mute to speak by using *7 Please mute your computer speakers and call into the phone line

2. Welcome to Today’s Call Please confirm your hospital is in attendance (if you miss roll call – please e-mail Stephanie by 4 pm)

3. Today’s Agenda • Announcements • Site Visit Update from Judy 2. Reducing/Preventing Hospital Acquired Conditions 3. 90 Day Challenge Slides (continued) 4. Wrapping up Cohort 2

4. Reducing / Preventing Hospital Acquired Conditions Nationwide, for every 1,000 hospital patients admitted: • 49 patients experienced adverse drug events (accounting for 34.1% of HACs). • 40 patients developed pressure ulcers (27.8 %). • 27 patients developed some other hospital-acquired condition (18.8 %). • 12 patients developed catheter-associated urinary tract infections (8.4 %). • 8 patients fell while in the hospital (5.5%). • 3 patients developed surgical site infections (2.1%). • 3 patients experienced obstetric adverse events (1.7%).

5. “Attacking” the HACs

6. TCAB Teams You have the skills to apply systematic improvement to reduce or prevent any Hospital Acquired Condition….

7. Intend to continue? WHA is currently recruiting for Partners for Patients initiatives

8. “Active” Improvement Teams are the Key • Prioritize which HAC would benefit from an active team • Teams consist of front-line staff and unit leaders • Gather knowledge & evidence • Guide improvement • Measure and Monitor the results

9. Learning while Improving • Monthly Webinar format by topic for Active Teams • Same day and time each month, beginning in March • One hour – recorded for later access • 30 minutes of Data, Evidence, Best Practices & Presentations • 30 minutes of “How to” instruction on applying systematic improvement • Teams will have 30-Day Action Items to select from to help adapt and adopt best practices

10. Webinars Alone ≠ Improvement Active Teams have 4 Deliverables: Attend/view monthly webinar and complete action items Submit monthly outcome measure data Submit monthly process measure data Share progress, learnings, and best practices about implementing changes on webinars and discussions

11. Learning Resources Monthly webinars reference the WHA Improvement Workbook Tools and Templates are also available for download from the WHA Quality Center

13. 90 Day Challenge Slides(Continued)

14. TOPIC: Nursing Vitality Scores DATE:01/07/2014 HOSPITAL: Agnesian Healthcare (SAH) Lessons Learned Measure Aim Statement: • What will be done differently as a result of this improvement process • 1.What will be done differently as a result of this improvement process • •Work on projects that are quick wins if the end date is 3 month. • •Bring in the other disiplines early to get their feedback. • •Increase awareness for the associates working through the process. Often reminders of the change implimented. • 1.Increase Vitality score by 1-2% Root Cause(s)? Follow Up • 1.What is the cause of the problem? • •Associates not working as a team • •Staff turn-over • •Too many “hoops” to implement changes • •IT issues with Advanced Care Documentation • What are the next steps? • Implement Break Buddies on all the units. • •Work with volunteer Services to implement a partnership to help with patients that need to talk or want companionship. • •Encourage nurses to use the new medication sheets routinely. • •Continue to try to get a Compliment Hotline started

15. TOPIC: Observation Patients and Problems Associated with the Use of Home Meds DATE: January 3, 2014 HOSPITAL: Aurora Lakeland Medical Center Lessons Learned Aim Statement: Measure • What will be done differently as a result of this improvement process • Formation of an interdisciplinary team to address designated storage area and process for ensuring that the patient is discharged with their home meds. • What was your 90 day aim? Implement a process for the identification and administration of home meds in the observation patient. This is to include the appropriate storage of the meds and subsequent return to the patient at discharge while the patient is hospitalized. Root Cause(s)? Follow Up • What is the cause of the problem? • What are the next steps? Creation of a formal process to address the issues/barriers of home meds in the observation patient

16. TOPIC: Increase Time at the Bedside DATE: 12/28/2013 HOSPITAL: Aurora Sinai Lessons Learned Aim Statement: Measure • 1.) Focus again on supplies and equipment. Are they available, in working condition and readily accessible. • 2.) Need to continue to enforce real time charting in rooms. • 3.) Need to work on bedside reporting at shift change. Some staff are willing to try it and adopt it, while others still are reluctant. • 4.) Hourly rounding has been adopted and is working. • 5.) Implement rounding with MD’s and nursing staff when rounding on patients. • Will repeat time study in one month and see if the inventions we have placed above will increase our time at the bedside to 65%. • Aim was to increase time at bedside to 60%. • Goal was met, 61% of RN’s time was spent at the bedside Root Cause(s)? 1.) Supplies and equipment issues 2.) Time management 3.) Poor shift to shift report/ transition 4.) Reluctance to change 5.) MD’s rounding on patients without nursing staff Follow Up Test Cycles 1.) Re-introduced Bedside reporting with RN’s and purposeful rounding -Staff willing to adapt and adopt 2.) Hourly rounding -Adopted and working 3.) Re-addressed supplies and equipment issue

17. TOPIC: Bedside Shift Reporting DATE: 1/2/2014 HOSPITAL: Froedtert Health: CMH - Med Lessons Learned Aim Statement: Measure • Increased patient involvement in plan of care enhances overall patient satisfaction with nurse communication. • Identify barriers to bedside report prior to implementation. Ours was time, once this was decreased it was an easier transition. • You need a few dedicated staff to keep the ball rolling and people motivated to continue bedside report. • 1. By December 31, 2013, 75% of patients will answer yes to a question about participation in planning their care. • According to collected data, 100% of patients called feel involved in their plan of care since implementation. Root Cause(s)? Pre TCAB Kardex Bedside • Patients felt separate from the care they were receiving. Care was done “to them” not “with them”. • Some important information was being missed on patients that were staying for long periods of time. Follow Up • Auditing compliance and use of bedside shift report

18. Patient Education Discharge Teaching 01/08/2013 Milwaukee VA Medical Center Lessons Learned Aim Statement: Measure • What will be done differently as a result of this improvement process • Discharge teaching will begin upon admission instead of the day of discharge. Also, there will be specified teaching topics individualized to each veteran based on their medical conditions and teaching needs. • What was your 90 day aim?. • Our aim is to pilot a new process for implementing patient discharge teaching upon admission. It will be a detailed process followed by all staff on the unit. Root Cause(s)? • What is the cause of the problem? • Currently, there is no standardized process for determining discharge teaching needs or timeframes for completing discharge teaching. Follow Up • What are the next steps? • The next steps are to implement the pilot, obtain feedback from staff, and make adjustments based upon these recommendations prior to full implementation.

19. TOPIC: Team Vitality DATE: 1/1/14 HOSPITAL: Spooner Health System Lessons Learned Aim Statement: Measure a) Staff will stop chatting and wait until the end of report for each patient to ask questions. b) Staff will ask how well a patient is known thereby preventing leaving out pertinent information to new nurses c)Recommend to expand use of whiteboards in patient room to communicate further info ie: fall risk, activity level, diet, etc. d)Recommend use of white board for staff in report room. Percentage of 5/5 responses Shift Change Patient Handoff mo/yr Info. Exchange Info Exchange 10/12 32 24 03/13 25 5 10/13 25 15 (Will not have results of test until next survey) • What was your 90 day aim?. • Increase % of nurses who score 5/5 to the questions regarding communication between shifts and hand-off communication on the Team Vitality Survey. Root Cause(s)? • What is the cause of the problem? • a) Hand off from ED to floor feels rushed, not enough time to ask questions. • b)Distraction is a large issue during report and at handoff., especially when sidebar conversations take place. • c)unable to find reporting RN in a timely manner to ask questions after listening to taped report. • d)Information is not always thorough during report. • e) Some staff give oral report and others tape report. Follow Up • What are the next steps? • a) Coach/teach staff to use SBAR during report. • b) Nursing Management to be approached regarding option of assignments, role of charge nurse, use of staff white board. • c) Continue to investigate pro’s/con’s of taped vs. verbal report.

20. TOPIC: Bedside Report DATE: Jan 2014 HOSPITAL: Mercy Hospital Lessons Learned Aim Statement: Measure • Share testimonials from nurse to nurse about benefits of change process • Temperature check of unit and team prior to implementing change process • Encourage and praise • Share progress with other departments Place Run Chart or Graph here • Increase bedside report compliance by 50% on all shifts through standardizing bedside report process Root Cause(s)? • Miscommunication • Lack of confidence • Fear of change in process • Misunderstanding of process Follow Up • Continue temperature check • Onboarding of new staff • Problem solving and intervention • Remain open to improvements

21. TOPIC: Increase ambulation to decrease falls DATE: 1/7/2014 HOSPITAL: William S. Middleton Memorial VA Hospital Lessons Learned Aim Statement: Measure • What will be done differently as a result of this improvement process • Consistent documentation of ambulation in a specific section of the nurse shift summary note as identified by nursing and other disciplines caring for the patient. • Increased awareness which will increase staff commitment to patient ambulation • What was your 90 day aim? • Increase purposeful patient ambulation and staff awareness of the need to ambulate through standardized documentation. Root Cause(s)? • What is the cause of the problem? • Nurses had different perceptions on where ambulation should be documented • There was no guide of measurement in the hallway to assist staff with documentation of distance Follow Up • What are the next steps? • Evaluate effectiveness in ambulation program for those patients that are high fall risk

22. DATE: 1/9/13 TOPIC: Break Buddies HOSPITAL: St. Elizabeth Hospital Lessons Learned Measure f • What will be done differently as a result of this improvement process? • Continue to engage associates in a supportive manner and listen to their ideas • Management coach associates who habitually miss their meal break • Staff need to use scripting with patients to inform them of the staff break time and meet needs prior to taking their break • Share the results with associates regularly to track progress Aim Statement: • What was your 90 day aim?. • 1. Decrease # of No-Lunch punches by 50% • 2. Decrease dollars paid to employees for no-lunch punches by 50% Follow Up Root Cause(s)? • What are the next steps? • Punching in and out during lunch break to ensure all employees have a 30 minute uninterrupted break • Staff MUST hand-off phones for break so we’ll purchase an extra phone to use on breaks for personal calls • Spread our progress with other Ministry hospitals • What is the cause of the problem? • Staff kept their phones with them on break and were constantly interrupted when trying to have a 30 minute break • Staff needed to hand their phones off to someone so they could actually take a break • Staff required education on fatigue and the importance of taking a break Cycle 1: 2 RNS Cycle 2: 4 RNS paired Cycle 3: 6 RNS paired Cycle 4: 6 RNS & 2 TCS paired Cycle 5: 6 RNS, 4 TCS, UC paired

23. TOPIC: Nurse Server Stocking DATE: January 2013 HOSPITAL: WFH-Franklin Lessons Learned Measure Aim Statement: • Important to make sure that locking mechanisms on nurse servers are easy to use. • Our keyholes were not easy to use so for new construction looking at a different options for locking mechanisms. • What was your 90 day aim?. To decrease amount of time that is spent between running and gathering supplies by stocking the nurse server. Root Cause(s)? • What is the cause of the problem? • Nurse servers were not stocked with the most frequently used supplies so staff would spend a greater amount of time hunting and gathering instead of spending it with patients. Follow Up • What are the next steps? Is to gather our post implementation step data week of January 13th.

24. TOPIC: Fall Prevention DATE: Jan 8 HOSPITAL: Aurora Memorial Hospital - Burlington Lessons Learned Aim Statement: Measure • What will be done differently as a result of this improvement process • There will be guidelines based on the Morse fall scale of 45 or greater that the beds will be set as follows. • Brake on, Bed plugged into nurse call system, side rails up, bed in low position, bed alert on and programed to zone two, ibed on. All alarms are programed into every staffs phone and if the alarm goes off everyone goes. • Fall tree on the unit with leaves placed with every day there is no falls, if a fall occurs all the leaves will come off. • We will have no falls for 100 days. Place Run Chart or Graph here Root Cause(s)? • What is the cause of the problem? • Increase in falls from July thru September that doubled our yearly fall total. Did not meet our goal of no falls with injury and to reduce falls my 50% from previous years total. Follow Up • What are the next steps? • Bed audits to ensure all the above criteria are met • No further falls for the 100 days we set for out goal.

25. TOPIC: Medication Education DATE:11/1/13 HOSPITAL: Calumet Medical Center Lessons Learned Aim Statement: Measure • Time consuming- needs to be done prior to discharge • Provider compliance is a challenge • Written info appreciated by patients • Pt education is easier and consistent with medication cheat sheet. To improve and be consistent with medication education and documenting purpose of med in patient copy of med list at least by 50% in 90 days. Manual audit of patient copy of med list at discharge to reflect purpose HCAHPS: Understood the purpose of medication Root Cause(s)? • Patient don’t always know their meds and its purpose – potentially impacting compliance. • Pt education is inconsistent and lacking ( purpose, side effects and when best to take) Follow Up • Manual audit for med-purpose and reinforce • Work with providers to improve documentation • Encourage use of med-educ cheat sheet for consistency, validate on rounding with patient

26. TOPIC: Discharge teaching DATE: 1/7/14 HOSPITAL: Hayward Area Memorial Hospital Lessons Learned Aim Statement: Measure • What will be done differently as a result of this improvement process? • A randomized audit of charts was done for the month of November and December to audit for documentation of “teach back” on discharge. This audit found nursing used teach back in 38% of the randomized chart review in November and 39% in December. • Nursing will be re-educated on the teach back method and the importance. • What was your 90 day aim? • Increase patient satisfaction with discharge education as evidenced by an increase in HCHAPS scores by 12/31/13.flkasjflkdjflkjsdfkljf Root Cause(s)? • What is the cause of the problem? • Nursing was instructing the patient on discharge, in regards to signs and symptoms and medications. However, the patient was not always understanding what was being taught. Therefore, when the patients returned home, the HCAHPS scores reflected that the patient did not feel that teaching was done to prepare them for self care at home. Follow Up • What are the next steps? • To continue to audit the use of teach back and trend HCAHPS scores related to patient understanding of medications and discharge instructions. • Re-educate Nursing on “teach back” method.

27. Summarizing Lessons Learned from the 90 Day Challenge

28. Wrapping Up Cohort 2 What we need from you: • Complete data submission through March 30 • Do last Time at the Bedside measurement • Do last Team Vitality • Report out on April webinar: what would you do differently if you started TCAB now? • Send a 3 question narrative summary

29. Cohort 2 Summary Narrative • What has been the most significant impact of TCAB on your unit? • What change or improvement has your unit adopted that you are most proud of? • What would you do differently if you started TCAB now?

30. Wrapping Up Cohort 2 What we will provide you: • A final CNO Report • Final write up of Cohort 2 • Quarterly TCAB Spread Coaching Calls May, August, November

32. Questions?