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Kaleidoscope Perinatal Neonatal & Women’s
Symposium
February 21, 2014Susan M. Distefano
CEO
The Leadership Challenge:Our World is Changing….
2
What is Going On In Healthcare?
3
Medicaid Expansion
Risk Pool
Bronze Plan
Three simple but bold “triple aims”»Better Care»Better Health»Lower Cost
4
Institute for HealthcareImprovement
Flipping U.S. Healthcare to Prevention….
5
Leadership
Essential to any solution: Leadership
6
Galvanizing LeadersPope Francis ‐ embraces the world
7
Galvanizing LeadersNelson Mandela – dared to insist on equality
8
Galvanizing Leaders
Oprah Winfrey – not about “me”
9
Galvanizing LeadersTEAM USA Olympics………Lindsey Vonn
…I’m still a winner
10
• What does this have to do with me?
• Do you have to be famous to be effective?
12
If healthcare changes are going to work we need leaders at all levels
But I’m just a:
ManagerBedside ClinicianEducator
13
Video
• Leadership at an early age…..
Young boy who made a cardboard amusement park
• http://vimeo.com/40000072
14
Leadership QualitiesInspireActGet someone to follow!
15
Video
Leadership:Single person dancing in the field• W:\HER\HER ‐ Customer Experience\Videos\First Follower‐
Leadership Lessons from Dancing Guy.wmv
16
Closer to home…..
New CMS Perinatal Core Measures:•PC01 Elective delivery <39 weeks
•PC02 CD rate for nulliparous women; team; singleton; vertex
•PC03 Antenatal steroid >24 wks and <32 wks
•PC04 Healthcare associated bacterial infection rate in neonates
•PC05 Exclusive breast feeding
17
Perinatal Care Core Measure PC‐01
18
CMHH PC-01 Elective Delivery Less Than 39 Completed WeeksPerinatal Care
(Lower is Better)
Source fi le date: 1/14/2014Generated: 1/14/2014 3:08:45 PM Reporting Months
p ro du ced by System Qu a l i t y a nd Pa t i en t Sa fe ty
Mean = 11.5
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May
2013 2014
0
10
20
30
40
50
60
70
80
90
100
CMHH PC-01 Elective Delivery Less Than 39 Completed WeeksPerinatal Care
(Lower is Better)
Source fi le date: 1/14/2014Generated: 1/14/2014 3:08:45 PM Reporting Months
p ro du ced by System Qu a l i t y a nd Pa t i en t Sa fe ty
Mean = 11.5
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May
2013 2014
0
10
20
30
40
50
60
70
80
90
100
CMHH PC-01 Elective Delivery Less Than 39 Completed WeeksPerinatal Care
(Lower is Better)
Source fi le date: 1/14/2014Generated: 1/14/2014 3:08:45 PM Reporting Months
p ro du ced by System Qu a l i t y a nd Pa t i en t Sa fe ty
Mean = 11.5
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May
2013 2014
0
10
20
30
40
50
60
70
80
90
100
CMHH PC-01 Elective Delivery Less Than 39 Completed WeeksPerinatal Care
(Lower is Better)
Source fi le date: 1/14/2014Generated: 1/14/2014 3:08:45 PM Reporting Months
p ro du ced by System Qu a l i t y a nd Pa t i en t Sa fe ty
Mean = 11.5
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May
2013 2014
0
10
20
30
40
50
60
70
80
90
100
CMHH PC-01 Elective Delivery Less Than 39 Completed WeeksPerinatal Care
(Lower is Better)
Source fi le date: 1/14/2014Generated: 1/14/2014 3:08:45 PM Reporting Months
p ro du ced by System Qu a l i t y a nd Pa t i en t Sa fe ty
Mean = 11.5
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May
2013 2014
0
10
20
30
40
50
60
70
80
90
100
CMHH PC-01 Elective Delivery Less Than 39 Completed WeeksPerinatal Care
(Lower is Better)
Source fi le date: 1/14/2014Generated: 1/14/2014 3:08:45 PM Reporting Months
p ro du ced by System Qu a l i t y a nd Pa t i en t Sa fe ty
Mean = 11.5
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May
2013 2014
0
10
20
30
40
50
60
70
80
90
100
CMHH PC-01 Elective Delivery Less Than 39 Completed WeeksPerinatal Care
(Lower is Better)
Source fi le date: 1/14/2014Generated: 1/14/2014 3:08:45 PM Reporting Months
p ro du ced by System Qu a l i t y a nd Pa t i en t Sa fe ty
Mean = 11.5
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May
2013 2014
0
10
20
30
40
50
60
70
80
90
100
CMHH PC-01 Elective Delivery Less Than 39 Completed WeeksPerinatal Care
(Lower is Better)
Source fi le date: 1/14/2014Generated: 1/14/2014 3:08:45 PM Reporting Months
p ro du ced by System Qu a l i t y a nd Pa t i en t Sa fe ty
Mean = 11.5
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May
2013 2014
0
10
20
30
40
50
60
70
80
90
100
CMHH PC-01 Elective Delivery Less Than 39 Completed WeeksPerinatal Care
(Lower is Better)
Source fi le date: 1/14/2014Generated: 1/14/2014 3:08:45 PM Reporting Months
p ro du ced by System Qu a l i t y a nd Pa t i en t Sa fe ty
Mean = 11.5
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May
2013 2014
0
10
20
30
40
50
60
70
80
90
100
CMHH PC-01 Elective Delivery Less Than 39 Completed WeeksPerinatal Care
(Lower is Better)
Source fi le date: 1/14/2014Generated: 1/14/2014 3:08:45 PM Reporting Months
p ro du ced by System Qu a l i t y a nd Pa t i en t Sa fe ty
Mean = 11.5
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May
2013 2014
0
10
20
30
40
50
60
70
80
90
100
CMHH PC-01 Elective Delivery Less Than 39 Completed WeeksPerinatal Care
(Lower is Better)
Source fi le date: 1/14/2014Generated: 1/14/2014 3:08:45 PM Reporting Months
p ro du ced by System Qu a l i t y a nd Pa t i en t Sa fe ty
Mean = 11.5
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May
2013 2014
0
10
20
30
40
50
60
70
80
90
100
Strategic Actions:Perinatal Core Measures:
All PC‐01, PC‐02, PC‐04 cases reviewed by Dr. Blackwell
Physicians and nurses attending Best Fed Beginnings as part of 10 step Baby Friendly designation
Leaders working on “scripting tool” for physicians and nurses re Best Fed initiative
Dr. Blackwell is working with physician groups to assure reason for C/S (PC‐2) documentation is appropriate
A physician template for documentation of “mother’s choice” is being developed
Focus to assure “mother’s choice” is documented prior to first feed to meet requirements
Removing availability of formula from nursery
Dr. Blackwell is developing a monthly score card for physicians related to PC measures
Kirsten Benjamin met with Dr. Blackwell 12/19/13 to discuss implementing a “hard stop” for H&Ps on scheduled deliveries
Perinatal Care Core MeasurePC‐02a ‐ 05
19
CMHH PC-05 Exclusive Breast Milk FeedingPerinatal Care
(Higher is Better)
Source file date: 1/14/2014Generated: 1/14/2014 3:08:49 PM Reporting Months
p ro d u ce d b y Syste m Qu a l i ty a n d Pa t i e n t Sa fe ty
Mean = 25.17
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May
2013 2014
0
10
20
30
40
50
60
70
80
90
100
CMHH PC-05 Exclusive Breast Milk FeedingPerinatal Care
(Higher is Better)
Source file date: 1/14/2014Generated: 1/14/2014 3:08:49 PM Reporting Months
p ro d u ce d b y Syste m Qu a l i ty a n d Pa t i e n t Sa fe ty
Mean = 25.17
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May
2013 2014
0
10
20
30
40
50
60
70
80
90
100
CMHH PC-05 Exclusive Breast Milk FeedingPerinatal Care
(Higher is Better)
Source file date: 1/14/2014Generated: 1/14/2014 3:08:49 PM Reporting Months
p ro d u ce d b y Syste m Qu a l i ty a n d Pa t i e n t Sa fe ty
Mean = 25.17
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May
2013 2014
0
10
20
30
40
50
60
70
80
90
100
CMHH PC-05 Exclusive Breast Milk FeedingPerinatal Care
(Higher is Better)
Source file date: 1/14/2014Generated: 1/14/2014 3:08:49 PM Reporting Months
p ro d u ce d b y Syste m Qu a l i ty a n d Pa t i e n t Sa fe ty
Mean = 25.17
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May
2013 2014
0
10
20
30
40
50
60
70
80
90
100
CMHH PC-05 Exclusive Breast Milk FeedingPerinatal Care
(Higher is Better)
Source file date: 1/14/2014Generated: 1/14/2014 3:08:49 PM Reporting Months
p ro d u ce d b y Syste m Qu a l i ty a n d Pa t i e n t Sa fe ty
Mean = 25.17
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May
2013 2014
0
10
20
30
40
50
60
70
80
90
100
CMHH PC-05 Exclusive Breast Milk FeedingPerinatal Care
(Higher is Better)
Source file date: 1/14/2014Generated: 1/14/2014 3:08:49 PM Reporting Months
p ro d u ce d b y Syste m Qu a l i ty a n d Pa t i e n t Sa fe ty
Mean = 25.17
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May
2013 2014
0
10
20
30
40
50
60
70
80
90
100
CMHH PC-05 Exclusive Breast Milk FeedingPerinatal Care
(Higher is Better)
Source file date: 1/14/2014Generated: 1/14/2014 3:08:49 PM Reporting Months
p ro d u ce d b y Syste m Qu a l i ty a n d Pa t i e n t Sa fe ty
Mean = 25.17
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May
2013 2014
0
10
20
30
40
50
60
70
80
90
100
CMHH PC-05 Exclusive Breast Milk FeedingPerinatal Care
(Higher is Better)
Source file date: 1/14/2014Generated: 1/14/2014 3:08:49 PM Reporting Months
p ro d u ce d b y Syste m Qu a l i ty a n d Pa t i e n t Sa fe ty
Mean = 25.17
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May
2013 2014
0
10
20
30
40
50
60
70
80
90
100
CMHH PC-05 Exclusive Breast Milk FeedingPerinatal Care
(Higher is Better)
Source file date: 1/14/2014Generated: 1/14/2014 3:08:49 PM Reporting Months
p ro d u ce d b y Syste m Qu a l i ty a n d Pa t i e n t Sa fe ty
Mean = 25.17
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May
2013 2014
0
10
20
30
40
50
60
70
80
90
100
CMHH PC-05 Exclusive Breast Milk FeedingPerinatal Care
(Higher is Better)
Source file date: 1/14/2014Generated: 1/14/2014 3:08:49 PM Reporting Months
p ro d u ce d b y Syste m Qu a l i ty a n d Pa t i e n t Sa fe ty
Mean = 25.17
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May
2013 2014
0
10
20
30
40
50
60
70
80
90
100
CMHH PC-05 Exclusive Breast Milk FeedingPerinatal Care
(Higher is Better)
Source file date: 1/14/2014Generated: 1/14/2014 3:08:49 PM Reporting Months
p ro d u ce d b y Syste m Qu a l i ty a n d Pa t i e n t Sa fe ty
Mean = 25.17
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May
2013 2014
0
10
20
30
40
50
60
70
80
90
100
CMHH PC-02a Cesarean Section - OverallPerinatal Care
(Lower is Better)
Source fi le date: 1/14/2014Generated: 1/14/2014 3:08:46 PM Reporting Months
p ro d u ce d b y Syste m Qu a l i t y a n d Pa t i e n t Sa fe ty
Mean = 32.05
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May
2013 2014
0
10
20
30
40
50
60
70
80
90
100
CMHH PC-02a Cesarean Section - OverallPerinatal Care
(Lower is Better)
Source fi le date: 1/14/2014Generated: 1/14/2014 3:08:46 PM Reporting Months
p ro d u ce d b y Syste m Qu a l i t y a n d Pa t i e n t Sa fe ty
Mean = 32.05
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May
2013 2014
0
10
20
30
40
50
60
70
80
90
100
CMHH PC-02a Cesarean Section - OverallPerinatal Care
(Lower is Better)
Source fi le date: 1/14/2014Generated: 1/14/2014 3:08:46 PM Reporting Months
p ro d u ce d b y Syste m Qu a l i t y a n d Pa t i e n t Sa fe ty
Mean = 32.05
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May
2013 2014
0
10
20
30
40
50
60
70
80
90
100
CMHH PC-02a Cesarean Section - OverallPerinatal Care
(Lower is Better)
Source fi le date: 1/14/2014Generated: 1/14/2014 3:08:46 PM Reporting Months
p ro d u ce d b y Syste m Qu a l i t y a n d Pa t i e n t Sa fe ty
Mean = 32.05
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May
2013 2014
0
10
20
30
40
50
60
70
80
90
100
CMHH PC-02a Cesarean Section - OverallPerinatal Care
(Lower is Better)
Source fi le date: 1/14/2014Generated: 1/14/2014 3:08:46 PM Reporting Months
p ro d u ce d b y Syste m Qu a l i t y a n d Pa t i e n t Sa fe ty
Mean = 32.05
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May
2013 2014
0
10
20
30
40
50
60
70
80
90
100
CMHH PC-02a Cesarean Section - OverallPerinatal Care
(Lower is Better)
Source fi le date: 1/14/2014Generated: 1/14/2014 3:08:46 PM Reporting Months
p ro d u ce d b y Syste m Qu a l i t y a n d Pa t i e n t Sa fe ty
Mean = 32.05
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May
2013 2014
0
10
20
30
40
50
60
70
80
90
100
CMHH PC-02a Cesarean Section - OverallPerinatal Care
(Lower is Better)
Source fi le date: 1/14/2014Generated: 1/14/2014 3:08:46 PM Reporting Months
p ro d u ce d b y Syste m Qu a l i t y a n d Pa t i e n t Sa fe ty
Mean = 32.05
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May
2013 2014
0
10
20
30
40
50
60
70
80
90
100
CMHH PC-02a Cesarean Section - OverallPerinatal Care
(Lower is Better)
Source fi le date: 1/14/2014Generated: 1/14/2014 3:08:46 PM Reporting Months
p ro d u ce d b y Syste m Qu a l i t y a n d Pa t i e n t Sa fe ty
Mean = 32.05
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May
2013 2014
0
10
20
30
40
50
60
70
80
90
100
CMHH PC-02a Cesarean Section - OverallPerinatal Care
(Lower is Better)
Source fi le date: 1/14/2014Generated: 1/14/2014 3:08:46 PM Reporting Months
p ro d u ce d b y Syste m Qu a l i t y a n d Pa t i e n t Sa fe ty
Mean = 32.05
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May
2013 2014
0
10
20
30
40
50
60
70
80
90
100
CMHH PC-02a Cesarean Section - OverallPerinatal Care
(Lower is Better)
Source fi le date: 1/14/2014Generated: 1/14/2014 3:08:46 PM Reporting Months
p ro d u ce d b y Syste m Qu a l i t y a n d Pa t i e n t Sa fe ty
Mean = 32.05
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May
2013 2014
0
10
20
30
40
50
60
70
80
90
100
CMHH PC-02a Cesarean Section - OverallPerinatal Care
(Lower is Better)
Source fi le date: 1/14/2014Generated: 1/14/2014 3:08:46 PM Reporting Months
p ro d u ce d b y Syste m Qu a l i t y a n d Pa t i e n t Sa fe ty
Mean = 32.05
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May
2013 2014
0
10
20
30
40
50
60
70
80
90
100
CMHH PC-03 Preterm Delivery Antenatal SteroidsPerinatal Care
(Higher is Better)
Source file date: 1/14/2014Generated: 1/14/2014 3:08:47 PM Reporting Months
p ro d u ce d b y Syste m Qu a l i ty a n d Pa t i e n t Sa fe ty
Mean = 97.73
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May
2013 2014
0
10
20
30
40
50
60
70
80
90
100
CMHH PC-03 Preterm Delivery Antenatal SteroidsPerinatal Care
(Higher is Better)
Source file date: 1/14/2014Generated: 1/14/2014 3:08:47 PM Reporting Months
p ro d u ce d b y Syste m Qu a l i ty a n d Pa t i e n t Sa fe ty
Mean = 97.73
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May
2013 2014
0
10
20
30
40
50
60
70
80
90
100
CMHH PC-03 Preterm Delivery Antenatal SteroidsPerinatal Care
(Higher is Better)
Source file date: 1/14/2014Generated: 1/14/2014 3:08:47 PM Reporting Months
p ro d u ce d b y Syste m Qu a l i ty a n d Pa t i e n t Sa fe ty
Mean = 97.73
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May
2013 2014
0
10
20
30
40
50
60
70
80
90
100
CMHH PC-03 Preterm Delivery Antenatal SteroidsPerinatal Care
(Higher is Better)
Source file date: 1/14/2014Generated: 1/14/2014 3:08:47 PM Reporting Months
p ro d u ce d b y Syste m Qu a l i ty a n d Pa t i e n t Sa fe ty
Mean = 97.73
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May
2013 2014
0
10
20
30
40
50
60
70
80
90
100
CMHH PC-03 Preterm Delivery Antenatal SteroidsPerinatal Care
(Higher is Better)
Source file date: 1/14/2014Generated: 1/14/2014 3:08:47 PM Reporting Months
p ro d u ce d b y Syste m Qu a l i ty a n d Pa t i e n t Sa fe ty
Mean = 97.73
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May
2013 2014
0
10
20
30
40
50
60
70
80
90
100
CMHH PC-03 Preterm Delivery Antenatal SteroidsPerinatal Care
(Higher is Better)
Source file date: 1/14/2014Generated: 1/14/2014 3:08:47 PM Reporting Months
p ro d u ce d b y Syste m Qu a l i ty a n d Pa t i e n t Sa fe ty
Mean = 97.73
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May
2013 2014
0
10
20
30
40
50
60
70
80
90
100
CMHH PC-03 Preterm Delivery Antenatal SteroidsPerinatal Care
(Higher is Better)
Source file date: 1/14/2014Generated: 1/14/2014 3:08:47 PM Reporting Months
p ro d u ce d b y Syste m Qu a l i ty a n d Pa t i e n t Sa fe ty
Mean = 97.73
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May
2013 2014
0
10
20
30
40
50
60
70
80
90
100
CMHH PC-03 Preterm Delivery Antenatal SteroidsPerinatal Care
(Higher is Better)
Source file date: 1/14/2014Generated: 1/14/2014 3:08:47 PM Reporting Months
p ro d u ce d b y Syste m Qu a l i ty a n d Pa t i e n t Sa fe ty
Mean = 97.73
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May
2013 2014
0
10
20
30
40
50
60
70
80
90
100
CMHH PC-03 Preterm Delivery Antenatal SteroidsPerinatal Care
(Higher is Better)
Source file date: 1/14/2014Generated: 1/14/2014 3:08:47 PM Reporting Months
p ro d u ce d b y Syste m Qu a l i ty a n d Pa t i e n t Sa fe ty
Mean = 97.73
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May
2013 2014
0
10
20
30
40
50
60
70
80
90
100
CMHH PC-03 Preterm Delivery Antenatal SteroidsPerinatal Care
(Higher is Better)
Source file date: 1/14/2014Generated: 1/14/2014 3:08:47 PM Reporting Months
p ro d u ce d b y Syste m Qu a l i ty a n d Pa t i e n t Sa fe ty
Mean = 97.73
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May
2013 2014
0
10
20
30
40
50
60
70
80
90
100
CMHH PC-03 Preterm Delivery Antenatal SteroidsPerinatal Care
(Higher is Better)
Source file date: 1/14/2014Generated: 1/14/2014 3:08:47 PM Reporting Months
p ro d u ce d b y Syste m Qu a l i ty a n d Pa t i e n t Sa fe ty
Mean = 97.73
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May
2013 2014
0
10
20
30
40
50
60
70
80
90
100
CMHH PC-04 Bacteremia in High-Risk NewbornsPerinatal Care
(Lower is Better)
Source fi le date: 1/14/2014Generated: 1/14/2014 3:08:48 PM Reporting Months
p ro d u ce d b y Syste m Qu a l i t y a n d Pa t i e n t Sa fe ty
Mean = 3.68
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May
2013 2014
0
10
20
30
40
50
60
70
80
90
100
CMHH PC-04 Bacteremia in High-Risk NewbornsPerinatal Care
(Lower is Better)
Source fi le date: 1/14/2014Generated: 1/14/2014 3:08:48 PM Reporting Months
p ro d u ce d b y Syste m Qu a l i t y a n d Pa t i e n t Sa fe ty
Mean = 3.68
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May
2013 2014
0
10
20
30
40
50
60
70
80
90
100
CMHH PC-04 Bacteremia in High-Risk NewbornsPerinatal Care
(Lower is Better)
Source fi le date: 1/14/2014Generated: 1/14/2014 3:08:48 PM Reporting Months
p ro d u ce d b y Syste m Qu a l i t y a n d Pa t i e n t Sa fe ty
Mean = 3.68
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May
2013 2014
0
10
20
30
40
50
60
70
80
90
100
CMHH PC-04 Bacteremia in High-Risk NewbornsPerinatal Care
(Lower is Better)
Source fi le date: 1/14/2014Generated: 1/14/2014 3:08:48 PM Reporting Months
p ro d u ce d b y Syste m Qu a l i t y a n d Pa t i e n t Sa fe ty
Mean = 3.68
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May
2013 2014
0
10
20
30
40
50
60
70
80
90
100
CMHH PC-04 Bacteremia in High-Risk NewbornsPerinatal Care
(Lower is Better)
Source fi le date: 1/14/2014Generated: 1/14/2014 3:08:48 PM Reporting Months
p ro d u ce d b y Syste m Qu a l i t y a n d Pa t i e n t Sa fe ty
Mean = 3.68
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May
2013 2014
0
10
20
30
40
50
60
70
80
90
100
CMHH PC-04 Bacteremia in High-Risk NewbornsPerinatal Care
(Lower is Better)
Source fi le date: 1/14/2014Generated: 1/14/2014 3:08:48 PM Reporting Months
p ro d u ce d b y Syste m Qu a l i t y a n d Pa t i e n t Sa fe ty
Mean = 3.68
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May
2013 2014
0
10
20
30
40
50
60
70
80
90
100
CMHH PC-04 Bacteremia in High-Risk NewbornsPerinatal Care
(Lower is Better)
Source fi le date: 1/14/2014Generated: 1/14/2014 3:08:48 PM Reporting Months
p ro d u ce d b y Syste m Qu a l i t y a n d Pa t i e n t Sa fe ty
Mean = 3.68
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May
2013 2014
0
10
20
30
40
50
60
70
80
90
100
CMHH PC-04 Bacteremia in High-Risk NewbornsPerinatal Care
(Lower is Better)
Source fi le date: 1/14/2014Generated: 1/14/2014 3:08:48 PM Reporting Months
p ro d u ce d b y Syste m Qu a l i t y a n d Pa t i e n t Sa fe ty
Mean = 3.68
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May
2013 2014
0
10
20
30
40
50
60
70
80
90
100
CMHH PC-04 Bacteremia in High-Risk NewbornsPerinatal Care
(Lower is Better)
Source fi le date: 1/14/2014Generated: 1/14/2014 3:08:48 PM Reporting Months
p ro d u ce d b y Syste m Qu a l i t y a n d Pa t i e n t Sa fe ty
Mean = 3.68
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May
2013 2014
0
10
20
30
40
50
60
70
80
90
100
CMHH PC-04 Bacteremia in High-Risk NewbornsPerinatal Care
(Lower is Better)
Source fi le date: 1/14/2014Generated: 1/14/2014 3:08:48 PM Reporting Months
p ro d u ce d b y Syste m Qu a l i t y a n d Pa t i e n t Sa fe ty
Mean = 3.68
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May
2013 2014
0
10
20
30
40
50
60
70
80
90
100
CMHH PC-04 Bacteremia in High-Risk NewbornsPerinatal Care
(Lower is Better)
Source fi le date: 1/14/2014Generated: 1/14/2014 3:08:48 PM Reporting Months
p ro d u ce d b y Syste m Qu a l i t y a n d Pa t i e n t Sa fe ty
Mean = 3.68
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May
2013 2014
0
10
20
30
40
50
60
70
80
90
100
Leadership…at the Corporate level
Memorial Hermann Health System
• Safety is a core value• Leaders “own” safe outcomes
• System Goal: Become a High Reliability Organization (HRO)
20
High Reliability 2011‐12Certified Zero Awards
21
1. Zero Events2. 12 Consecutive Months3. Certified Zero Category
High Reliability Organization
9 Certified Zero Awards at MH-TMC1. TMC Adult: Retained Foreign Bodies (12 months)2. CMHH: Iatrogenic Pneumothorax (12 months)3. CMHH: Iatrogenic Pneumothorax (24 months)4. CMHH: Pressure Ulcers (12 months)5. CMHH: Pressure Ulcers (12 months)6. CMHH: Retained Foreign Bodies (12 months)7. CMHH: Retained Foreign Bodies (24 months)8. CMHH: Ventilator Associated Pneumonias (24 months)9. CMHH: Ventilator Associated Pneumonias (36 months)
Do No HarmPICU VAPs, CLABSIs NICU/PICU/Floor, Pedi SSIs, PICU CAUTI Counts
22
13-Jul 13-Aug 13-Sep 13-Oct 13-Nov 13-Dec 14-Jan 14-Feb 14-Mar 14-Apr 14-May 14-Jun FY14 Total
0 0 0 0 0 0 0
3 1 3 1 3 3 14
0 0 2 0 2 0 4
1 1 0 0 0 0 2
0 0 0 0 0 0 0
0
0
0 3 0 0 0 3
36.95 49.78 63.22 49.24 52.80 50.40
`
C. Difficile (LabID)
Pedi SSI
Surgeon Query Compliance (%)
PICU CLABSI
CAUTI PICU
CAUTI Floor
MRSA (LabID)
NICU CLABSI
MH-CMHH Infection Counts
CLABSI Floor
Surgeon Query Compliance (%)
Distinguished Target Threshold Concern
> 70.00% > 60.00% > 50.00% < 50.00%
HAI Infection Counts
Zero Cases Any Cases
0 > 0
Leadership in the Unit level
23
NICU Practice Changes to decrease infection:2008 Line Team Started ‐
(Surgical line management dressing change, blood draws, meds)
2009 Annual validations staff/line team competenciesDaily assessment re: line necessity
2011 Ethanol lock introduced
2012 “Press & Seal” for Ostomy patients with CL
2010‐12 Administered flu vaccine to staff, patients and family member
NICU Central Line Associated Blood Stream Infections (CLABSI)
CLA
BS
I Rat
e pe
r 1K
Lin
e D
ays
Memorial Hermann Healthcare SystemNICU Central Line Associated Blood Stream Infections
Source file date: 7/14/2012Generated: 7/14/2012 9:43:21 AM Reporting Months
produced by System Quality and Pat ient Safety
UCL = 19.19
Mean = 11.96
LCL = 4.74
UCL = 8.62
Mean = 3.45
UCL = 4.44
Mean = 1.62
Qtr 4
Qtr 1
Qtr 2
Qtr 3
Qtr 4
Qtr 1
Qtr 2
Qtr 3
Qtr 4
Qtr 1
Qtr 2
Qtr 3
Qtr 4
Qtr 1
Qtr 2
Qtr 3
Qtr 4
Qtr 1
Qtr 2
Qtr 3
Qtr 4
Qtr 1
2006 2007 2008 2009 2010 2011 2012
0
2
4
6
8
10
12
14
16
18
20
CLA
BS
I Rat
e pe
r 1K
Lin
e D
ays
Memorial Hermann Healthcare SystemNICU Central Line Associated Blood Stream Infections
Source file date: 7/14/2012Generated: 7/14/2012 9:43:21 AM Reporting Months
produced by System Quality and Pat ient Safety
UCL = 19.19
Mean = 11.96
LCL = 4.74
UCL = 8.62
Mean = 3.45
UCL = 4.44
Mean = 1.62
Qtr 4
Qtr 1
Qtr 2
Qtr 3
Qtr 4
Qtr 1
Qtr 2
Qtr 3
Qtr 4
Qtr 1
Qtr 2
Qtr 3
Qtr 4
Qtr 1
Qtr 2
Qtr 3
Qtr 4
Qtr 1
Qtr 2
Qtr 3
Qtr 4
Qtr 1
2006 2007 2008 2009 2010 2011 2012
0
2
4
6
8
10
12
14
16
18
20
CLA
BS
I Rat
e pe
r 1K
Lin
e D
ays
Memorial Hermann Healthcare SystemNICU Central Line Associated Blood Stream Infections
Source file date: 7/14/2012Generated: 7/14/2012 9:43:21 AM Reporting Months
produced by System Quality and Pat ient Safety
UCL = 19.19
Mean = 11.96
LCL = 4.74
UCL = 8.62
Mean = 3.45
UCL = 4.44
Mean = 1.62
Qtr 4
Qtr 1
Qtr 2
Qtr 3
Qtr 4
Qtr 1
Qtr 2
Qtr 3
Qtr 4
Qtr 1
Qtr 2
Qtr 3
Qtr 4
Qtr 1
Qtr 2
Qtr 3
Qtr 4
Qtr 1
Qtr 2
Qtr 3
Qtr 4
Qtr 1
2006 2007 2008 2009 2010 2011 2012
0
2
4
6
8
10
12
14
16
18
20
CLA
BS
I Rat
e pe
r 1K
Lin
e D
ays
Memorial Hermann Healthcare SystemNICU Central Line Associated Blood Stream Infections
Source file date: 7/14/2012Generated: 7/14/2012 9:43:21 AM Reporting Months
produced by System Quality and Pat ient Safety
UCL = 19.19
Mean = 11.96
LCL = 4.74
UCL = 8.62
Mean = 3.45
UCL = 4.44
Mean = 1.62
Qtr 4
Qtr 1
Qtr 2
Qtr 3
Qtr 4
Qtr 1
Qtr 2
Qtr 3
Qtr 4
Qtr 1
Qtr 2
Qtr 3
Qtr 4
Qtr 1
Qtr 2
Qtr 3
Qtr 4
Qtr 1
Qtr 2
Qtr 3
Qtr 4
Qtr 1
2006 2007 2008 2009 2010 2011 2012
0
2
4
6
8
10
12
14
16
18
20
CLA
BS
I Rat
e pe
r 1K
Lin
e D
ays
Memorial Hermann Healthcare SystemNICU Central Line Associated Blood Stream Infections
Source file date: 7/14/2012Generated: 7/14/2012 9:43:21 AM Reporting Months
produced by System Quality and Pat ient Safety
UCL = 19.19
Mean = 11.96
LCL = 4.74
UCL = 8.62
Mean = 3.45
UCL = 4.44
Mean = 1.62
Qtr 4
Qtr 1
Qtr 2
Qtr 3
Qtr 4
Qtr 1
Qtr 2
Qtr 3
Qtr 4
Qtr 1
Qtr 2
Qtr 3
Qtr 4
Qtr 1
Qtr 2
Qtr 3
Qtr 4
Qtr 1
Qtr 2
Qtr 3
Qtr 4
Qtr 1
2006 2007 2008 2009 2010 2011 2012
0
2
4
6
8
10
12
14
16
18
20
CLA
BS
I Rat
e pe
r 1K
Lin
e D
ays
Memorial Hermann Healthcare SystemNICU Central Line Associated Blood Stream Infections
Source file date: 7/14/2012Generated: 7/14/2012 9:43:21 AM Reporting Months
produced by System Quality and Pat ient Safety
UCL = 19.19
Mean = 11.96
LCL = 4.74
UCL = 8.62
Mean = 3.45
UCL = 4.44
Mean = 1.62
Qtr 4
Qtr 1
Qtr 2
Qtr 3
Qtr 4
Qtr 1
Qtr 2
Qtr 3
Qtr 4
Qtr 1
Qtr 2
Qtr 3
Qtr 4
Qtr 1
Qtr 2
Qtr 3
Qtr 4
Qtr 1
Qtr 2
Qtr 3
Qtr 4
Qtr 1
2006 2007 2008 2009 2010 2011 2012
0
2
4
6
8
10
12
14
16
18
20
CLA
BS
I Rat
e pe
r 1K
Lin
e D
ays
Memorial Hermann Healthcare SystemNICU Central Line Associated Blood Stream Infections
Source file date: 7/14/2012Generated: 7/14/2012 9:43:21 AM Reporting Months
produced by System Quality and Pat ient Safety
UCL = 19.19
Mean = 11.96
LCL = 4.74
UCL = 8.62
Mean = 3.45
UCL = 4.44
Mean = 1.62
Qtr 4
Qtr 1
Qtr 2
Qtr 3
Qtr 4
Qtr 1
Qtr 2
Qtr 3
Qtr 4
Qtr 1
Qtr 2
Qtr 3
Qtr 4
Qtr 1
Qtr 2
Qtr 3
Qtr 4
Qtr 1
Qtr 2
Qtr 3
Qtr 4
Qtr 1
2006 2007 2008 2009 2010 2011 2012
0
2
4
6
8
10
12
14
16
18
20
CLA
BS
I Rat
e pe
r 1K
Lin
e D
ays
Memorial Hermann Healthcare SystemNICU Central Line Associated Blood Stream Infections
Source file date: 7/14/2012Generated: 7/14/2012 9:43:21 AM Reporting Months
produced by System Quality and Pat ient Safety
UCL = 19.19
Mean = 11.96
LCL = 4.74
UCL = 8.62
Mean = 3.45
UCL = 4.44
Mean = 1.62
Qtr 4
Qtr 1
Qtr 2
Qtr 3
Qtr 4
Qtr 1
Qtr 2
Qtr 3
Qtr 4
Qtr 1
Qtr 2
Qtr 3
Qtr 4
Qtr 1
Qtr 2
Qtr 3
Qtr 4
Qtr 1
Qtr 2
Qtr 3
Qtr 4
Qtr 1
2006 2007 2008 2009 2010 2011 2012
0
2
4
6
8
10
12
14
16
18
20
CLA
BS
I Rat
e pe
r 1K
Lin
e D
ays
Memorial Hermann Healthcare SystemNICU Central Line Associated Blood Stream Infections
Source file date: 7/14/2012Generated: 7/14/2012 9:43:21 AM Reporting Months
produced by System Quality and Pat ient Safety
UCL = 19.19
Mean = 11.96
LCL = 4.74
UCL = 8.62
Mean = 3.45
UCL = 4.44
Mean = 1.62
Qtr 4
Qtr 1
Qtr 2
Qtr 3
Qtr 4
Qtr 1
Qtr 2
Qtr 3
Qtr 4
Qtr 1
Qtr 2
Qtr 3
Qtr 4
Qtr 1
Qtr 2
Qtr 3
Qtr 4
Qtr 1
Qtr 2
Qtr 3
Qtr 4
Qtr 1
2006 2007 2008 2009 2010 2011 2012
0
2
4
6
8
10
12
14
16
18
20
CLA
BS
I Rat
e pe
r 1K
Lin
e D
ays
Memorial Hermann Healthcare SystemNICU Central Line Associated Blood Stream Infections
Source file date: 7/14/2012Generated: 7/14/2012 9:43:21 AM Reporting Months
produced by System Quality and Pat ient Safety
UCL = 19.19
Mean = 11.96
LCL = 4.74
UCL = 8.62
Mean = 3.45
UCL = 4.44
Mean = 1.62
Qtr 4
Qtr 1
Qtr 2
Qtr 3
Qtr 4
Qtr 1
Qtr 2
Qtr 3
Qtr 4
Qtr 1
Qtr 2
Qtr 3
Qtr 4
Qtr 1
Qtr 2
Qtr 3
Qtr 4
Qtr 1
Qtr 2
Qtr 3
Qtr 4
Qtr 1
2006 2007 2008 2009 2010 2011 2012
0
2
4
6
8
10
12
14
16
18
20
CLA
BS
I Rat
e pe
r 1K
Lin
e D
ays
Memorial Hermann Healthcare SystemNICU Central Line Associated Blood Stream Infections
Source file date: 7/14/2012Generated: 7/14/2012 9:43:21 AM Reporting Months
produced by System Quality and Pat ient Safety
UCL = 19.19
Mean = 11.96
LCL = 4.74
UCL = 8.62
Mean = 3.45
UCL = 4.44
Mean = 1.62
Qtr 4
Qtr 1
Qtr 2
Qtr 3
Qtr 4
Qtr 1
Qtr 2
Qtr 3
Qtr 4
Qtr 1
Qtr 2
Qtr 3
Qtr 4
Qtr 1
Qtr 2
Qtr 3
Qtr 4
Qtr 1
Qtr 2
Qtr 3
Qtr 4
Qtr 1
2006 2007 2008 2009 2010 2011 2012
0
2
4
6
8
10
12
14
16
18
20
24
Leadership at the unit level…• NICUGoal: Zero bacterial catheter related infections.
(insert trend graph over last 3 years)
25
CLA
BSI R
ate
per 1K
Lin
e Day
s
CMHH NICU CLABSIDo No Harm
Central Line Associated Blood Stream Infections
Source fi le date:1/14/2014Generated: 1/14/2014 3:09:02 PM Reporting Months
p ro du ced b y System Qu a l i t y a nd Pa t i en t Sa fe ty
UCL = 6.28
Mean = 1.83
Jul
Aug
Sep
Oct
Nov
Dec Jan
Feb
Mar Ap
r
May Ju
n
Jul
Aug
Sep
Oct
Nov
Dec Jan
Feb
Mar Ap
r
May
2012 2013 2014
0.00
2.00
4.00
6.00
8.00
10.00
12.00
14.00
CLA
BSI R
ate
per 1K
Lin
e Day
s
CMHH NICU CLABSIDo No Harm
Central Line Associated Blood Stream Infections
Source fi le date:1/14/2014Generated: 1/14/2014 3:09:02 PM Reporting Months
p ro du ced b y System Qu a l i t y a nd Pa t i en t Sa fe ty
UCL = 6.28
Mean = 1.83
Jul
Aug
Sep
Oct
Nov
Dec Jan
Feb
Mar Ap
r
May Ju
n
Jul
Aug
Sep
Oct
Nov
Dec Jan
Feb
Mar Ap
r
May
2012 2013 2014
0.00
2.00
4.00
6.00
8.00
10.00
12.00
14.00
CLA
BSI R
ate
per 1K
Lin
e Day
s
CMHH NICU CLABSIDo No Harm
Central Line Associated Blood Stream Infections
Source fi le date:1/14/2014Generated: 1/14/2014 3:09:02 PM Reporting Months
p ro du ced b y System Qu a l i t y a nd Pa t i en t Sa fe ty
UCL = 6.28
Mean = 1.83
Jul
Aug
Sep
Oct
Nov
Dec Jan
Feb
Mar Ap
r
May Ju
n
Jul
Aug
Sep
Oct
Nov
Dec Jan
Feb
Mar Ap
r
May
2012 2013 2014
0.00
2.00
4.00
6.00
8.00
10.00
12.00
14.00
CLA
BSI R
ate
per 1K
Lin
e Day
s
CMHH NICU CLABSIDo No Harm
Central Line Associated Blood Stream Infections
Source fi le date:1/14/2014Generated: 1/14/2014 3:09:02 PM Reporting Months
p ro du ced b y System Qu a l i t y a nd Pa t i en t Sa fe ty
UCL = 6.28
Mean = 1.83
Jul
Aug
Sep
Oct
Nov
Dec Jan
Feb
Mar Ap
r
May Ju
n
Jul
Aug
Sep
Oct
Nov
Dec Jan
Feb
Mar Ap
r
May
2012 2013 2014
0.00
2.00
4.00
6.00
8.00
10.00
12.00
14.00
CLA
BSI R
ate
per 1K
Lin
e Day
s
CMHH NICU CLABSIDo No Harm
Central Line Associated Blood Stream Infections
Source fi le date:1/14/2014Generated: 1/14/2014 3:09:02 PM Reporting Months
p ro du ced b y System Qu a l i t y a nd Pa t i en t Sa fe ty
UCL = 6.28
Mean = 1.83
Jul
Aug
Sep
Oct
Nov
Dec Jan
Feb
Mar Ap
r
May Ju
n
Jul
Aug
Sep
Oct
Nov
Dec Jan
Feb
Mar Ap
r
May
2012 2013 2014
0.00
2.00
4.00
6.00
8.00
10.00
12.00
14.00
CLA
BSI R
ate
per 1K
Lin
e Day
s
CMHH NICU CLABSIDo No Harm
Central Line Associated Blood Stream Infections
Source fi le date:1/14/2014Generated: 1/14/2014 3:09:02 PM Reporting Months
p ro du ced b y System Qu a l i t y a nd Pa t i en t Sa fe ty
UCL = 6.28
Mean = 1.83
Jul
Aug
Sep
Oct
Nov
Dec Jan
Feb
Mar Ap
r
May Ju
n
Jul
Aug
Sep
Oct
Nov
Dec Jan
Feb
Mar Ap
r
May
2012 2013 2014
0.00
2.00
4.00
6.00
8.00
10.00
12.00
14.00
CLA
BSI R
ate
per 1K
Lin
e Day
s
CMHH NICU CLABSIDo No Harm
Central Line Associated Blood Stream Infections
Source fi le date:1/14/2014Generated: 1/14/2014 3:09:02 PM Reporting Months
p ro du ced b y System Qu a l i t y a nd Pa t i en t Sa fe ty
UCL = 6.28
Mean = 1.83
Jul
Aug
Sep
Oct
Nov
Dec Jan
Feb
Mar Ap
r
May Ju
n
Jul
Aug
Sep
Oct
Nov
Dec Jan
Feb
Mar Ap
r
May
2012 2013 2014
0.00
2.00
4.00
6.00
8.00
10.00
12.00
14.00
CLA
BSI R
ate
per 1K
Lin
e Day
s
CMHH NICU CLABSIDo No Harm
Central Line Associated Blood Stream Infections
Source fi le date:1/14/2014Generated: 1/14/2014 3:09:02 PM Reporting Months
p ro du ced b y System Qu a l i t y a nd Pa t i en t Sa fe ty
UCL = 6.28
Mean = 1.83
Jul
Aug
Sep
Oct
Nov
Dec Jan
Feb
Mar Ap
r
May Ju
n
Jul
Aug
Sep
Oct
Nov
Dec Jan
Feb
Mar Ap
r
May
2012 2013 2014
0.00
2.00
4.00
6.00
8.00
10.00
12.00
14.00
CLA
BSI R
ate
per 1K
Lin
e Day
s
CMHH NICU CLABSIDo No Harm
Central Line Associated Blood Stream Infections
Source fi le date:1/14/2014Generated: 1/14/2014 3:09:02 PM Reporting Months
p ro du ced b y System Qu a l i t y a nd Pa t i en t Sa fe ty
UCL = 6.28
Mean = 1.83
Jul
Aug
Sep
Oct
Nov
Dec Jan
Feb
Mar Ap
r
May Ju
n
Jul
Aug
Sep
Oct
Nov
Dec Jan
Feb
Mar Ap
r
May
2012 2013 2014
0.00
2.00
4.00
6.00
8.00
10.00
12.00
14.00
CLA
BSI R
ate
per 1K
Lin
e Day
s
CMHH NICU CLABSIDo No Harm
Central Line Associated Blood Stream Infections
Source fi le date:1/14/2014Generated: 1/14/2014 3:09:02 PM Reporting Months
p ro du ced b y System Qu a l i t y a nd Pa t i en t Sa fe ty
UCL = 6.28
Mean = 1.83
Jul
Aug
Sep
Oct
Nov
Dec Jan
Feb
Mar Ap
r
May Ju
n
Jul
Aug
Sep
Oct
Nov
Dec Jan
Feb
Mar Ap
r
May
2012 2013 2014
0.00
2.00
4.00
6.00
8.00
10.00
12.00
14.00
CLA
BSI R
ate
per 1K
Lin
e Day
s
CMHH NICU CLABSIDo No Harm
Central Line Associated Blood Stream Infections
Source fi le date:1/14/2014Generated: 1/14/2014 3:09:02 PM Reporting Months
p ro du ced b y System Qu a l i t y a nd Pa t i en t Sa fe ty
UCL = 6.28
Mean = 1.83
Jul
Aug
Sep
Oct
Nov
Dec Jan
Feb
Mar Ap
r
May Ju
n
Jul
Aug
Sep
Oct
Nov
Dec Jan
Feb
Mar Ap
r
May
2012 2013 2014
0.00
2.00
4.00
6.00
8.00
10.00
12.00
14.00
Baby Meets WorldGoal:• Implement “Baby Meets World” in Women’s Services at CMHH with a go live date of June 4th 2013. • 90% of healthy infants will go skin to skin (vaginal and C/S) within the first 5 minutes
• 100% of breastfeeding mothers will receive assistance and support with breastfeeding
• 90% percent of infants will room‐in with mothers and feed on cue
26
“Baby Meets World”
o Skin to skin within first 5 minuteso Breastfeeding within 1st hour of lifeo In room transition of the newborno Bedside hand offo Couplet careo Rooming‐ino Newborn bath in the roomo Single caregiver for mother and baby
Baby Meets World
Pre‐data collection
Skin to skin PDSA #1
Skin to skinPDSA # 2
Pre‐data collection
Checklist pilot
Bundle intervention
Increase room temperature to 77-80 degrees pre-delivery
Pre-warm warmers to 100% for 20 min. prior to delivery
At delivery, place baby skin to skin (≥ 36 weeks) or receive baby in WARM blanket and keep covered on way to warmer
Immediately remove wet blanket and place ISC probe
Take and record baseline temperature
Focus on the Baby
Thermoregulation Bundle
NICHQ Best Fed Beginnings
Vermont Oxford
VHAIHI
Perinatal Community
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
90.00%
Pre‐intervention Post‐intervention
Readiness to Perform Newborn Assessment
Scale 1‐5 (1= not ready, 5= ready)
12345
N=26 (40% in progress)N=33 (52%)
0%
10%
20%
30%
40%
50%
60%
Pre‐intervention Post‐intervention
D StronglyD SlightlyNeutralA SlightlyA Strongly
BMW Best Possible Care Model
N = 40 (63% N = 31 (47% in progress)
Rooming In Baby Meets World Go Live
One mother’s voice….• “I was very delighted to find out that they are encouraging mothers to bond with their baby. They placed my baby on my chest right after delivery and that’s exactly what I wanted. “
• …our newborn son’s temperature went a little bit lowand rather than taking him into the nursery and puttinghim under the lamp they had him lay on me skin‐to skinfor 30 minute intervals. They came back to check and his temperature rose back and remained normal.”
Our plans for the next phase of the Journey…..
• Provide all in‐room care for the newborn including pediatric exam and labs
• Expand the Mother Baby RN knowledge of transitional care of the newborn, thermoregulation
• Provide skin‐to‐skin in the OR• Improving exclusive breastfeeding rate• Decrease C/S rate through improved labor practices
35
Leaders :• Inspire, tell why, tell why again, and don’t dictate solutions.
• Start Staff meetings with Patient Story• Remember to focus on what is going well
Team Members :• Be engaged!• Give constructive input!• It doesn’t have to be perfect to try it out
36
“Losers assemble in little groups and complain about the coaches and players in other little groups. Winners assemble as a team.”
Caution:
38
Everyday we have the option to lead, follow or be a loser! Our communities, colleagues, families and patients are counting on us to lead the way.
Path Forward…
What is your role?•Leader•First Follower•Team Member•All the above
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