excellence in patient safety -...

Excellence in Patient SafetyNassau-Suffolk Hospital Council2010 Award PresentationDecember 6, 2010

The Nassau-Suffolk Hospital Council is proud that its member

hospitals strive continuously to improve the quality of care pro-

vided at their facilities and ensure the safety, well-being, and

appropriate treatment of every patient that comes through their

doors. To meet these challenges, every one of the Council’s

member hospitals is engaged in innovative, thoughtful, and

well-executed initiatives. The third annual Excellence in Patient

Safety Award recognizes the very best of this year’s efforts.

Kevin DahillPresident and Chief Executive Officer

The Nassau-Suffolk Hospital Council is privi-

leged to present the third annual Excellence in

Patient Safety Award to recognize one of its

members’ distinguished achievements in pa-

tient safety and quality improvement.

The nomination process was conducted in tan-

dem with the Healthcare Association of New

York State’s (HANYS) Pinnacle Award for Qual-

ity and Patient Safety. Submissions for the

Pinnacle Award were, with the permission of

each hospital, also considered for the Excel-

lence in Patient Safety Award. Nominees were

required to submit a project summary and nar-

rative that described the nominated quality im-

provement projects’ goals, innovation,

methodology, leadership involvement, execu-

tion, achievements, and impact on organiza-

tional efficiency.

Twenty-one institutions submitted 33 applica-

tions to HANYS and the Nassau-Suffolk Hospi-

tal Council for consideration. The nominations

were initially vetted and scored by the HANYS

Pinnacle Award review panel. The top ten ap-

plications then were reviewed and scored lo-

cally by a three-judge panel. The nominations

were scored for their impact on patient care

and safety, innovation, adherence to quality

improvement principles and methodologies,

use of relevant process and outcome meas-

ures and systems through the improvement

process, sustainability, evidence of cost-con-

sciousness, and demonstration of effective

use of human and material resources.

ABOUT THE AWARD

The Nassau-Suffolk Hospital Council is grateful to its panel

of reviewers for the time, dedication, and thoughtfulness

with which they approached the task of determining the

winner of the 2010 Excellence in Patient Safety Award.

We offer our special thanks to the judging panel:

Ilene CorinaPresident

PULSE of New York

Dianne Gianfelice, RNQuality Coordinator

Ambulatory Care and Community Medicine

Valerie Terzano, MS, RN, CNAVice President for Nursing

Winthrop-University Hospital

Brookhaven Memorial Hospital Medical Center Home Health AgencyHome Care Demonstration Project: Telehealth and Chronic Obstructive Pulmonary Disease 1(COPD) PatientsCatholic Health Services of Long IslandImproving Obstetric Patient Safety Outcomes through Crew Resource Metholodology 2Eastern Long Island HospitalCriminal Justice Treatment Program Addresses Treatment within Correctional Facilities 3and CourtsFranklin HospitalRestraint Reduction Strategies Improve Patient Safety 4Glen Cove HospitalThe Journey to Zero Nosocomial Infections 5Good Samaritan Hospital Medical CenterMid-Track: The Solution to the Emergency Severity Index (ESI) 3 Patient Timely Treatment 6ConundrumHuntington HospitalElectronic, Evidence-based Clinical Decision Rule Linked to Computerized Order Sets 7Proves Effective and SafeJohn T. Mather Memorial HospitalSave That Vein 8Mercy Medical CenterImproving Patient Flow at a Non-academic Hospital 9Acute Inpatient Rehabilitation Unit Fall Prevention Program 10Nassau University Medical CenterInformation Technology and Stroke Task Force Partnership 11Leadership Initiative and Behavior Modification Transform Platelet Utilization 12North Shore-Long Island Jewish Health SystemEnhancing Performance, Changing Culture, Improving Communication, and 13Supporting Rapid Cycle Change across a Multi-hospital Health Care System: The Collaborative Care ModelResponding to an Epidemic: Novel H1N1 Influenza, Key Principles of Health System 14Preparedness and ResponseNorth Shore University HospitalRemote Video Auditing with Feedback and Hand Hygiene Compliance 15Plainview HospitalDecreasing the Incidence of Upper Extremity Deep Venous Thrombus (UEDVT) in Patients 16with Peripherally-inserted Central Catheters (PICC)Pressure Ulcer Initiative 17

continued

St. Catherine of Siena Medical CenterWhen Seconds Count: Employing Six Sigma Strategies to Transient Ischemic Attack and 18Stroke ManagementVentilator-associated Pneumonia Prevention: “Automatic and Painless” 19St. Charles HospitalImproving Interdisciplinary Reporting of Pre-empted Medication Errors 20PUPs (Pressure Ulcer Prevention) Program 21St. Francis HospitalFeet First: Enhancing a Culture of Safety to Achieve a Reduction in Patient Falls 22Optimizing a Culture of Interdisciplinary Collaboration to Prevent Central Line-associated 23Blood Stream Infections (CLABs) in Critical CareSkin Integrity: Nursing Interventions and Clinical Nurse SKIN Champions 24South Nassau Communities HospitalMaintaining the Momentum on Patient Throughput 25Re-designing Processes to Prevent Hospital-acquired Venous Thromboembolism (VTE) 26Southampton HospitalA Nursing Strategic Plan Built Upon a Foundation of Patient Safety 27Southside HospitalImproving Pain Management in the Limited English Proficient (LEP) Population 28Stony Brook University Medical CenterFostering Organization-wide Use of Failure Mode and Effect Analyses (FMEA) 29Standardization to Prevent Venous Thromboembolism (VTE) 30Winthrop-University HospitalCode H Obstetrical Hemorrhage, Development of a Team Approach 31Got Milk? Vital: Human Milk for Premature Infants 32CPOE System Enhanced by Visual Cues 33

EXCELLENCE IN PATIENT SAFETY 2010 1

Catholic Health Services of Long Island

Improving Obstetric Patient Safety Outcomes through Crew Resource Methodology

In 2005, the perinatal performance improve-ment task force was chartered and chargedwith developing a strategy for system-wideimprovement in outcomes. After assessingthe various options for systems improvementand team training, the task force selectedthe Crew Resource Management (CRM)model as the methodology for change. Thismodel, developed by the National Aeronauti-cal and Space Administration in 1979, fo-cuses on improving safety by examining therole of human error in aviation accidents.

Team training was provided to a core groupof clinicians who then instructed everynurse, obstetrician, anesthesiologist, andneonatologist on the service at each of thethree hospitals. In total, 235 staff mem-bers were trained. The staff training ateach of the sites focused on enhancing situ-ational awareness and increasing the un-derstanding about how certain stressors(i.e. fatigue and poor communication) cancontribute to medical errors. The impor-tance of creating a culture where staff feelempowered to speak up if they believe a sit-uation may jeopardize patient safety wasemphasized, along with primary compo-nents of effective crew management includ-ing safety, efficiency, and teamwork.

Each unit adopted the core principlesaround communication, team structure, situ-ation monitoring, mutual support and teambehavior, including team rounding and hud-dles on each patient incident, debriefing andemergency drills. Nursing staff was encour-aged to invoke the two-challenge rule, wherethey would be responsible for assertively butrespectfully voicing concerns about a patientcare situation at least two times to ensurethey have been heard. If an issue remainsunresolved, the nurse is to contact a super-visor in the chain of command.

In order to evaluate the effectiveness of theprogram, a series of metrics were developedfollowing a thorough review of the peer litera-ture. After 18 months of implementation,significant improvements in the frequency ofadverse events, malpractice claims, andstaff perception on safety were achieved.Adverse events were reduced between 26and 42 percent. Malpractice claims were re-duced 66 percent. The severity index ofevents dropped between nine and 17 per-cent. Unexpected admission to the NeonatalIntensive Care Unit dropped by over 60 percent.

CONGRATULATIONS TO OUR 2010 AWARD WINNER

2 EXCELLENCE IN PATIENT SAFETY 2010

Brookhaven Memorial Hospital Medical Center Home Health Agency

Home Care Demonstration Project: Telehealth and Chronic Obstructive Pulmonary Disease (COPD) Patients

Brookhaven Memorial has a persistent vari-ance in re-admission rates under 30 daysafter hospital discharge of patients with pul-monary diseases. The project was to in-crease the number of patients dischargedto home care with these diagnoses andplace them on telehealth in order to reducethe 30-day re-admission rate to the hospitalwith exacerbation of pulmonary disease.

In conjunction with the hospital case man-agement department, registration depart-ment, and on-site coordinators for homecare, the pulmonary patients were targetedfor discharge to home care whenever possi-ble. The hospital’s certified home healthagency accepted the majority of these dis-charges with the goal of improving the re-admission rate and patient outcomes. Inaddition to placing these patients on homecare with the provision of skilled nursing,physical and/or occupational therapies, nu-tritional therapy, and/or home health aideservices, telehealth monitoring was alsoadded to the armamentarium to proactivelymanage symptoms prior to emergent need.

Patients were placed on home care, andthose that did not accept telehealth werestill seen in the standard manner with inter-mittent in-home visits. Those that did ac-cept telehealth were seen for fewer in-home

visits and frequent (3-7/week) telehealthnurse/patient interactions. Telehealth pa-tients had scales, blood pressure cuffs,pulse oximeters, and stethoscopes in theirhomes, as well as interactive visual comput-ers. Patients took their vital signs and sentthem to the nurse daily via computer/phoneconnection. Patients whose vital signs var-ied out of prescribed range were contactedby the nurse more frequently than thosewhose vital signs were stable. The base pe-riod was prior to the initiative (July-Decem-ber, 2007) and the improvement periodfollowed (July-December, 2008). The sus-taining period was measured (July-Decem-ber, 2009). The follow up period was theentire year of 2009.

For patients on home care without tele-health, the risk of re-hospitalization within30 days of hospital discharge is 17-20 per-cent and for those with telehealth it reducesto 4-4.5 percent. Patient satisfaction washigher in the telehealth patients versus thenon-telehealth patients. The non-telehealthpatient satisfaction rate was 88.8 percentand the telehealth patient satisfaction ratewas 95.6 percent.

✧HONORABLE MENTION

Eastern Long Island Hospital

Criminal Justice Treatment Program Addresses Treatment within Correctional Facilitiesand Courts

Eastern Long Island Hospital embarked onan innovative collaborative between crimi-nal justice agencies and a hospital-basedbehavioral health treatment continuum.The program focused on treatment groupswithin county correctional facilities, provid-ing a clinical advisor to the local drugcourts, and hospital services providing pri-mary treatment and assessment for thecounty’s re-entry program.

Treatment within the county correctional fa-cilities consisted of weekly groups for bothmen and women—on-going drop in groupsthat challenge criminal thinking and stresscognitive behavioral changes. The drugcourt clinical advisor, also a member of thetreatment team for the Regional InterventionCourt, sat twice weekly with the judge, coor-dinator, and probation officers to review anddesign the court’s treatment assessmentand plan. The Re-entry Task Force and hos-pital collaboration facilitates appropriate be-havioral health treatment and casemanagement for individuals being releasedfrom incarceration and those who are at riskof parole violation due to substance abuse.

Successful treatment of the criminal justiceoffender/patient is dependent upon under-standing that both criminality and substanceabuse must be addressed in order to

increase recovery for the offender. Educa-tion for behavioral health staff regardingcriminality and criminal thinking is imperativefor the successful treatment of offenders.

Outcomes achieved included three years oftreatment groups provided within two cor-rectional facilities. Approximately 884 in-mates per year served in both correctionalfacilities. One hundred fifty six paroleeshave been treated within the hospital-basedbehavioral health continuum.


Franklin Hospital

Restraint Reduction Strategies Improve Patient Safety

The implementation of a multidisciplinaryFall/Restraint Committee, along with ongo-ing staff education, documentation monitor-ing and review resulted in a decrease by 22percent in restraint use and greater use ofalternatives. In addition, the program ac-tively engaged the patient in safe care byproviding them with a Fall Contract.

The committee set out to reduce the re-straint index by 10 percent by the end of2009. Entering the program, the committeeunderstood that staff were unaware of alter-natives that were as effective but more re-spectful and that restraint use was higheron evening/night shifts. Ongoing staff infor-mation and education was key to the suc-cess of this initiative. That educationincluded review of documentation to en-sure appropriateness of restraint use. Thecommittee looked at the name of restraintused, reason for the restraint, number ofepisodes, reviewed the MD order and docu-mentation, what alternative restraints wereattempted, the time limit involved, and theface-to-face evaluation by a Licensed Inde-pendent Practitioner.

The Restraint/Fall Committee conductedrandom chart review of patients in re-straints. As staff members were actively in-volved in this process, this enlightened

them about the lack of documentation. Oneof the main goals of the initiative was to im-prove overall documentation on alternativesused and attempts to release restraints.Restraint use can increase hospital lengthof stay for those patients awaiting skillednursing facility or rehab placement, asthese facilities require patients to be off re-straints for at least 24 hours before admis-sion. To ensure the continued effectivenessof the program, the Fall/Restraint Commit-tee has champions who are charged withpromoting alternatives to restraint use onunits.


Glen Cove Hospital

The Journey to Zero Nosocomial Infections

As part of the patient safety and quality im-provement program, Glen Cove Hospital fo-cused on the reduction of central line-associated blood stream infections (CLABS)in the critical care unit (CCU). The hospital’sCCU is comprised of cardiac care, medicaland surgical patients. Focus was placed oncentral lines as they are high risk and high volume.

An opportunity for improvement was identi-fied in 2005, as the CLAB rate in criticalcare was 6.5/per 1,000 line days. RootCause Analysis and Failure Mode Analysiswere the methodologies used to identify is-sues, as well as prioritize and modify prac-tices. Changes in culture and practice haveled to excellent outcomes, improved patientsafety, decreased length of stay and costavoidance.

Lewin’s change principle was also appliedto change culture in the following areas: ad-herence to standards for line insertion,maintenance, and compliance of best prac-tice and empowerment of nursing staff.This encouraged leading from the bottomup rather than the top down, utilizing thecollaborative model.

Maintaining compliance with best practices,empowering staff, and continuously evaluat-ing practices has resulted in significant im-provement in preventing adverse outcomesfor patients. As of March 15, 2010, the fa-cility achieved 812 CLAB-free days and 375ventilator-associated pneumonia-free days.Additionally, Glen Cove saw a 52 percent re-duction in nosocomial Methicillan-resistantStaphylococcus Aureus from 2008–2009.



Good Samaritan Hospital Medical Center

Mid-Track: The Solution to the Emergency Severity Index (ESI) 3 Patient Timely TreatmentConundrum

Good Samaritan Hospital participated in anational collaborative dedicated to find, de-velop, and deliver strategies to improve pa-tient flow and reduce EmergencyDepartment (ED) crowding. Patients enter-ing an overcrowded ED face longer waittimes for care, which often results in peopleleaving without being seen (LWBS). Pa-tients seen in mid-track were those non-emergent cases (ESI 3 patients) who arrivedwith one of six chief complaints: vaginalbleeding, pregnancy complication, vomiting,abdominal pain, headache, or flank pain(this made up the study population)

It was determined that the ESI 3 (mid sever-ity) patients had the longest wait times andhad a high ‘left without being seen (LWBS)rate.’ From these data the team developedthe mid-track initiative to find a solution toaddress the needs of the ESI 3 patients in amore timely and efficient manner.

The mid-track initiative dedicated a physi-cian to manage the diagnostic phase forthese patients directly after their triage.The patients were treated utilizing the Am-bulatory Surgery Unit (ASU) space locateddirectly over the ED and their care was di-rected by that same physician and coordi-nated by nurse practitioners (NPs). The NPwas supported by a nurse and an emer-

gency technician. In addition to the physicians and nursing, a phlebotomy techrole was deemed to be mission critical.

The mid-track operated Monday–Friday, 4p.m.–midnight, utilizing the proximate ASUspace during its off hours to provide a no-cost solution for additional flex-space.

This innovative and effective care deliverysystem will be permanently incorporatedinto the operating procedures for patientspresenting at our ED.

Documented improvements included a re-duction for the LWBS rate for all ESI 3 pa-tients of 36 percent and 42 percent for thestudy group. Overall LWBS rate was re-duced by nearly 24 percent. There has alsobeen an upward trend in ED patient satisfaction.


Huntington Hospital

Electronic, Evidence-based Clinical Decision Rule Linked to Computerized Order SetsProves Effective and Safe

Immune-mediated heparin-induced throm-bocytopenia (HIT) is associated with limb-threatening arterial thromboses and venousthromboembolism with the risk of fatal pul-monary embolism. Accurately identifyingpatients in need of high-cost testing andtreatment is complicated by the fact thatthis condition must be distinguished frommore common, non-immune thrombocy-topenia in patients receiving heparinoids.An evidence-based clinical decision rule ex-ists that can improve diagnostic accuracy,but is not widely utilized. This is a high-volume, high-risk clinical problem because alarge fraction of all inpatients receive he-parinoids for thromboprophylaxis, and HIT isknown to occur in 0.8 percent and 2 per-cent to 3 percent of patients receiving low-molecular weight and unfractionatedheparin, respectively.

A multidisciplinary working group adapted apublished, evidence-based clinical decisionrule for use in an electronic decision-sup-port module accessible through our hospi-tal’s intranet. Plan-Do-Study-Act and RapidCycle Change methodologies were utilized.Champions and project leaders includedone hospitalist in collaboration with a full-time Pharm.D., and a full-time clinical phar-macist. There was consultative supportfrom our nurse practitioner-lead

anticoagulation service and leadership sup-port from the chief medical officer. Initialtesting was by a small number of participat-ing hospitalists who served as our earlyadopters. Spread of this practice was thenachieved across our Internal Medicine Hos-pitalist program, which manages more than80 percent of all admissions to the depart-ment of medicine. Feedback was providedat twice monthly meetings of the hospitalistgroup and electronically.

The initiative resulted in a total heparin-induced platelet antibody (HIPA) test de-crease of 55.6 percent. Negative HIPA as-says decreased 84 percent. Serotoninrelease assay testing decreased 25 per-cent. Unnecessary argatroban courses de-creased from six (2008 baseline) to zero.Total argatroban use increased by 41 per-cent during the post-implementation period,reflecting avoidance of “under-use” errorsdetected during the baseline phase. Under-use outliers decreased seven patients tozero.


John T. Mather Memorial Hospital

Save That Vein

Recognizing the risks for patients receivingvarious intravenous medications and in-fusates, the Nursing Executive Committeededicated a full-time position for an InfusionTherapy Coordinator. The core of this posi-tion is the National Patient Safety Goal(NPSG 07.04.01): Implement Best Practiceor Evidence Based Guidelines to preventCentral Line Associated Blood Stream Infec-tions (CLABSI). The Infusion Therapy Coordi-nator developed a program to incorporatethe 17 elements of performance listed inthe safety goal including short-term periph-eral intravenous access.

An action plan was developed in conjunc-tion with, but not limited to, the following:Informational Services; Registered Nurses;Nursing Information Service; Infection Pre-vention Department; Medical Staff; Materi-als Management; Nursing Education;Nursing Quality Management and SterileProcessing. The Patient/Caregiver re-mained the focus in every component of theaction plan. The plan also included dailyvascular access rounds with attention to thevarious performance indicators. When thestandard was not met, a patient/situation-specific nursing education in-service is con-ducted with the nurse responsible for thepatient. At the time of rounds, the patient’sinfusion needs are discussed to either

maintain or remove the access, or consideran alternate vascular access device (VAD).

One of the most exciting outcomes reportedby the project leaders is when a nurse rec-ognizes a standard has not been met andconsults with the Infusion Therapy Coordina-tor (ITC). The ITC assesses the situationand provides appropriate education. In ad-dition, the ITC sends a letter of recognitionto the nurse who identified a standard wasnot met. The letter includes the follow-upaction with the number of nurses that werere-educated/in-serviced.

In addition to improved clinical outcomesand enhanced patient safety, the initiativehas found cost-savings for the facilitythrough a decrease in length of stay forICU/CCU patients. Central line-associatedblood stream infection rate was also sub-stantially reduced.



Mercy Medical Center

Improving Patient Flow at a Non-academic Hospital

Crowding and prolonged boarding in MercyMedical Center’s relatively small emergencydepartment was leading to poor outcomesand even sentinel events. Morale through-out the hospital was challenged, which wasreflected by significant customer frustrationand poor financial performance. The pro-longed boarding was attributable, in part, tononcompetitive patient lengths of stay(LOS), especially for skilled nursing facility(SNF) patients. The admission process andplan-of-care of SNF and unassigned pa-tients were inefficient compared to non-SNFpatients. It was clear that the incentives forthe voluntary physicians who cared for SNFpatients and the hospital were not aligned.

Analysis revealed physician practice pat-terns with complex geriatric patients wereassociated with mean lengths of stay (LOS)in excess of 10 days, lifting the hospital’soverall LOS to 7.6 days. These practice pat-terns resulted in excessive use of scarcecritical care and telemetry resources, allleading to delays in discharge and ulti-mately in patient flow directly impactingemergency room processes of care. Metricswere far in excess of national norms.

The solution was the development of a Geriatric Care Best Practice Program and aunique “contractual arrangement” with

physicians. The contract required thatphysicians who desired to treat skilled nurs-ing facility patients agree to implement bestpractices, including use of standard ordersets, systematic monitoring and feedbackon care outcomes. Patients experienceddramatic improvements in lengths of stay,emergency department waiting time, andnursing sensitive indicators like pressure ul-cers. Emergency department and inpatientsatisfaction scores skyrocketed, with im-provement up by 10 to 20 percent in everycategory. An improvement of 20 percent inlengths of stay and nearly 15 percent im-provement in overall hospital lengths of staywere accomplished. These achievementsare sustained to this day.


Mercy Medical Center

Acute Inpatient Rehabilitation Unit Fall Prevention Pprogram

Keeping with the hospital’s culture of safety,fall prevention monitoring lead to a closerlook at Mercy’s Acute Inpatient Rehabilita-tion population. It was noted that 90 per-cent of patients that fell in December 2009were cerebral vascular accident patients.Twenty-two percent of the patients that fellhad left-sided CVA’s, 67 percent had right-sided CVA’s and 11 percent had bilateralCVA’s. This data lead the hospital to a fur-ther study of right-sided brain injury and aneducational opportunity for the staff. As aresult, changes have been initiated to theexisting Fall Prevention Program that has afocus for right-sided brain injury patients.

In anticipation of the right-sided brain injurypatients’ impulsivity and spatial/perceptualissues, the following was implemented: lo-cate patients in rooms closest to the nurs-ing station; have bed exit alarms engaged atall times; apply chair alarms when the pa-tient was out of bed; add a smile face sym-bol to the Fall Potential Alert found on thepatient’s room door to further identify theright-sided brain injury. In addition, differ-ent color non-skid slipper socks used by theright-sided brain injury patient led to easierdifferentiation of these patients at a quickglance.

The cost of the improvement effort was min-imal—the purchase of chair alarms and thecolor-coded non-skid socks—and the resultsand benefit to patients were notable. Therewere no other associated costs to this im-provement initiative. In one month’s timeafter initiating the revised Fall PreventionProgram with a focus on right-sided brain in-jury, the hospital’s fall rate decreased 27percent for this population.


Nassau University Medical Center

Information Technology and Stroke Task Force Partnership

As a New York State-designated stroke cen-ter, Nassau University Medical Center fol-lows best practice standards and dischargeguidelines developed by the American HeartAssociation. Through retrospective chart re-view, quality management had identifiedgaps in data retrieval and areas for improve-ment. Recognizing that stroke managementis very time sensitive and that ED doctorsneed to make critical decisions regardingtreatments, the Plan-Do-Check-Act modelwas applied to the patient-entry componentof their stay. Identified were issues with in-consistent stroke code initiation, problemswith validation due to inconsistent datasources or missing data and time lag inpractitioner feedback. The goal: to facili-tate the ease and ensure the validity of doc-umentation and provide real-time drilldowns with immediate plans of correction.To accomplish this, an information technol-ogy solution was developed and initiated inApril 2008. Triggered by presumptive strokeICD-9 codes, stroke team activation is auto-matic, a stroke order set populates the field,date and time fields are auto-populated andan e-mail is generated and sent to all disci-plines capturing key quality indicators.

The program’s wide-reaching goals were tosupport delivery of evidence-based qualitycare that meets or exceeds the facility’s

mission statement to provide high-qualitycare to all; to develop strategies to enhancecommunication between all levels of patientcare; to provide tools for leadership to per-form practitioner-specific real-time drilldowns enabling immediate plans of correc-tion; to facilitate the ease and accuracy ofrequired documentation; and to initiate anautomated system to capture data.

Outcomes achieved included: 228 percentincrease in stroke patients that had arecorded NIH Stroke Scale score; 36 per-cent increase for stroke patients who had aCT scan less than 25 minutes from arrival;158 percent increase for stroke patientswho had a recorded last well known arrivaltime to identify the earliest possible timethat stroke symptoms began; and 126 per-cent increase in validation of acute is-chemic stroke patients not being treatedwith IV t-PA due to exclusion criteria.


Nassau University Medical Center

Leadership Initiative and Behavior Modification Transforms Platelet Utilization

The issue of unused expired platelet unitswas raised by front-line staff in a leadership-driven “town hall meeting.” UtilizingFOCUS/PDCA methodology, the blood bankdepartment identified an opportunity for im-provement in the area of health care profes-sionals’ knowledge regarding plateletutilization. Prior to implementing change,the rate of platelet units becoming outdatedwas 28.4 percent. Management initiatedclose observation and expert consultationby blood bank staff during requests forplatelets. The intention was to identify ifmodification of health care professionals’behavior and culture would result in im-provement in platelet utilization. Monitoringfor the ensuing 332 days revealed a de-crease in the rate of outdated platelet unitsto 6.3 percent. This decrease translatesinto an annual savings of 70.9 plateletunits, representing a $50,631 cost savings.

Health care professionals became more fo-cused and sensitive to the precious re-source and utilization of platelets followingconsultation with blood bank staff. This al-lowed for a sharp decline in outdatedplatelet units.

More importantly, quality and safety of pa-tient care improved by efficient use of thisproduct, and exposure to the hazard of

blood product transfusion was reduced with-out compromising patient care. Enhance-ment and satisfaction of management dueto more efficient patient care, increased sav-ings, and making progress in budgetary andlabor allocation with resource adjustmentwere outcomes of this initiative. In addition,the program engendered the bolstering ofblood bank staff’s morale, sense of belong-ing, and job satisfaction.


North Shore-Long Island Jewish Health System

Enhancing Performance, Changing Culture, Improving Communication, and SupportingRapid Cycle Change across a Multi-Hospital Healthcare System: The Collaborative CareModel®

As a multi-hospital healthcare system, NorthShore engages in continuous quality andsafety initiatives. The staff, faced with com-peting priorities and incessant innovations,often regard new strategies as another flavorof the month. Many changes have not beensustainable. Analyzing the outcomes andimpact of numerous strategies for practiceimprovement and advancement, it was evi-dent that the staff needed to transform itsculture to orchestrate a different approach.

The approach entailed development and im-plementation of a values-based, patient-centered model intended to translate thesystem’s mission, vision and values into thedaily practice of patient care. The Collabo-rative Care Model® provides the infrastruc-ture for implementation of rapid cyclechanges and supports the widespread com-munication necessary for sustainment.

A pilot site in a community hospital was es-tablished in 2007. Training was provided toevery staff person regardless of role or posi-tion. Training included development of unit-and department-based Collaborative CareCouncils, tools to support rapid cyclechange and Team Strategies and Tools toEnhance Performance and Patient Safety, orTeamSTEPPS, for communication. Selectedquality, cultural and safety metrics were

monitored. Significant improvements wereidentified and have been extended and sus-tained. The model and training are nowbeing expanded to the entire organization.

In one year, education about the model andtools to facilitate effective communicationwas delivered to over 19,000 employeesacross 14 hospitals. Over 75 percent of pa-tient care areas have interdisciplinary Col-laborative Care Councils, the cornerstonestructure to support realization of themodel. These councils have spread to sup-port, ancillary, and allied health services.



North Shore-Long Island Jewish Health System

Responding to an Epidemic: Novel H1N1 Influenza, Key Principles of Health System Preparedness and Response

Effectively responding to large scale (mass)public health crises is a demanding chal-lenge. Establishing an initial urgent re-sponse to the 2009 H1N1 outbreak in orderto meet the needs of patients, the commu-nity and healthcare workers, as well as astrategic plan for managing the H1N1 epi-demic and potential resurgence in the com-munity presented unique challenges to thesystem.

The system’s Emergency Operations Plan(EOP) is a defined leadership priority thatwas set into motion in the spring of 2009when the system became the epicenter ofthe H1N1 epidemic. Critical internal re-sources were mobilized to meet the urgentdemands placed on system hospitals, aswell as the health care needs of the localcommunities. The laboratory rapidlyprocessed thousands of viral specimenswhich helped define the scope of the prob-lem and support public policy on testing forH1N1. Anticipating a potential resurgencein H1N1 during the 2009-2010 flu season,the system partnered with the local Com-missioner of Health to establish communityoutreach and a strategic vaccination pro-gram. The success of the EOP and re-sponse to public health needs was achievedthrough effective surge plans; targeted clini-cal decision making and protocol design,

development, and deployment; expansion oflaboratory capabilities; use of real-time datafor administrative and clinical decision mak-ing; powerful social media campaigns; novelcommunity education through a flu mi-crosite; community outreach and mass im-munization efforts; mapping based oncensus population to determine Points ofDistribution (PODs) for high-risk, high-needpopulations; and strategic partnerships withlocal, state and federal agencies.

The program adheres to quality improve-ment principles using the Plan-Do-Check-Act(PDCA) methodology. The effectiveness ofthe system’s response to the H1N1 epi-demic and potential resurgence was evalu-ated based upon these principles andtechniques. During the initial surge of theoutbreak, more than 12,000 patients wereevaluated, 36,000 lab tests were per-formed, 485 patients were admitted, and,during the post-surge, approximately17,000 individuals were vaccinated, with56.2 percent from high-priority groups.



North Shore University Hospital

Remote Video Auditing with Feedback and Hand Hygiene Compliance

In March 2008, video cameras were placedwith views of every sink and hand sanitizerdispenser in the hallways and patient roomsto record hand hygiene compliance. Sen-sors mounted in the doorways identifiedwhen health care workers entered or exited,indicating a hand hygiene event. Whenvideo auditors observed health care work-ers using the hand sanitizer dispenser orwashing hands with soap and water, theyassigned a “pass” to the event. Auditors in-dicated a “fail” when they observed thepractice not being performed.

Baseline rates for hand hygiene compliancewere recorded from June through the firstweek of October 2008. On October 6, 2008the results of the audits were displayed ontwo electronic boards visible to all staff inthe unit. The results were updated every 10minutes with current shift, weekly, andmonthly rates. Unit managers also receivede-mailed summaries delineating shift,weekly, and monthly rates. Leadership re-sponded to low rates of hand hygiene com-pliance largely on an aggregate basis, butcoached individuals as needed. Hand hy-giene increased and has been sustained.

Before the feedback period, hand hygienerates were less than 10 percent. With con-tinuous real-time feedback, hand hygiene

exceeded 85 percent for the 14-month re-view period. Further, weekly compliancerates for physicians were lower than that ofother health care providers and results dur-ing the day shift were lower than during thenight shift.

By using remote video auditing with feed-back in the intensive care unit, the facilitywas able to improve and sustain high ratesof hand hygiene compliance for fourteenmonths, as well as to reduce healthcare-ac-quired infections. North Shore UniversityHospital now aims to expand this approachto additional critical care units across otherhospitals in the health system.


Plainview Hospital

Decreasing the Incidence of Upper Extremity Deep Venous Thrombus (UEDVT) in Patients with Peripherally Inserted Central Catheters (PICC)

This institution’s quality management de-partment, through the efforts of its utiliza-tion managers, identified in 2008 anincreased incidence of UEDVTs occurring inthose patients who had PICC lines inserted.Also noted was a significant increase in thenumber of PICCs inserted—537 in 2007 and902 in 2008.

PICCs are convenient, safe and cost-effec-tive in both the in-patient and out-patientsettings. Plainview Hospital focused its ef-forts and strategies on preventing UEDVT inthose patients who have indwelling PICClines. A proactive risk assessment was uti-lized in order to determine if the currentPICC process was in need of improvement.A multidisciplinary team was establishedand included representation from physi-cians, nursing, and the departments of radi-ology and quality management. Thefacility’s in-depth analysis into the PICCprocess included the inception of the JointCommission’s 2010 Patient Safety Goal re-quirements for Central Venous Catheters(prior to the mandated target date); a re-design to the hospital’s current PICCprocess; reinforcement of proper PICC care;recommendations for PICC insertions; andseveral other process improvements. Theresults from the analysis along with thecommittee’s recommendations were

disseminated to the staff through the ef-forts of the hospital’s educational depart-ment. The improvement strategies thatwere designed and implemented led to amajor reduction in the development of UED-VTs, as well as a decrease in the number ofcentral-line bloodstream infections.

Some specific improvements include a de-crease in the number of PICCs insertedfrom 902 in 2008 to 677 in 2009, as wellimproved compliance with completion ofPICC consents and the catheter insertionnote. The hospital’s progress continuestoday.



Plainview Hospital

Pressure Ulcer Initiative

In 2009, the hospital created a PressureUlcer Initiative with the intent of accurateidentification of pressure ulcers, both community-acquired and nosocomial. Inaddition, the initiative sought to provide ap-propriate, cost- effective treatment and thecollection of data that can be compared toother validated data bases. The hospital’sgoal was to improve outcomes by reducingthe incidence of facility-acquired pressureulcers from two percent to one and a halfpercent.

The hospital recognized its high risk andhigh volume population. Patients from thecommunity include those that reside in nurs-ing homes, rehabilitation facilities and grouphomes. Approximately 65 percent of thehospital’s population is older than 70. Inorder to succeed, the nursing process wasrestructured. After a review of current litera-ture and utilizing the National Pressure UlcerAdvisory Panel (NPUAP) and Wound OstomyContinence Nurse (WOCN) clinical practiceguidelines, a multidimensional initiative thatincluded nursing education, team buildingand standardization was introduced.

The initiative was rooted in education andtraining. The methods used included theadministration of a nationally-recognizedpressure ulcer training tool to all registered

nurses to ensure competency, formation ofa registered nurse Skin Resource Team,with representation from all med-surg andintensive care units, and the establishmentof “Wound Care Wednesday” to promoteconsistency in documentation. In addition,a wound care algorithm was designed topromote evidence-based treatment guide-lines established for pressure ulcer stageand presentation.

The program reduced the incidence of noso-comial pressure ulcers to one percent, wellbelow the national average of 5.3 percent.The Wound Care Algorithm promotes 100percent compliance with product selectionand the standardized formula allows thehospital to compare its results with nation-ally recognized data bases.


St. Catherine of Siena Medical Center

When Seconds Count: Employing Six Sigma Strategies to Transient Ischemic Attack andStroke Management

St. Catherine’s sought to achieve signifi-cant, robust and reliable improvements inTransient Ischemic Attack (TIA) and strokepatient management through utilization ofSix Sigma process improvement strategies.Senior leadership’s vision in 2006 yielded acommitment to improving the hospital’scompliance with published “best practices”to minimize the devastating functional,emotional and financial impact of these twoemergency events.

Stroke is the leading cause of serious long-term disability, and is the second leadingcause of death in industrialized nations.Every second in delay in treatment may re-duce the likelihood of a favorable patientoutcome. Partnering with the AmericanStroke and Heart Association (ASA/AHA) toimplement best practices as evidenced byimplementation of the “Get with the Guide-lines” (GWTG) performance measures forStroke Patient Management since 2006has yielded sustained enhanced quality ofcare. The hospital’s team and collaborativeefforts have achieved persistent improve-ments in the provision of defect-free care.In addition to providing consistent, reliablecare harmonized with evidence-based bestpractices, St. Catherine’s is poised to com-pete in the market place to draw patients tothe facility and assume a strategic position

to ensure appropriate reimbursement withthe future addition of Stroke/TIA as a coremeasure.

The goal of this non-academic communityhospital was to improve the efficiency of itsstaff in recognizing ischemic stroke patientswho were potential thrombolytic candidates,as well to improve overall compliance foreach of 10 performance measures identi-fied by the AHA/ASA as indicators of excel-lence in Stroke/TIA patient management.

When compared with the baseline period,the improvement period saw a 33 percentincreased rate of rt-PA utilization; 34 per-cent improvement DVT prophylaxis compli-ance; 67percent increase in anticoagulationtherapy at discharge; 65 percent increase inpatients discharged on cholesterol reducingagents; 26 percent increase in documenta-tion of dysphagia screen; and an 83 percentincrease in documentation of stroke education.


St. Catherine of Siena Medical Center

Ventilator-associated Pneumonia Prevention: “Automatic and Painless”

Ventilator-associated Pneumonia (VAP) is a

problem that not only prolongs hospitalization

time with negative outcomes and sometimes

even death for those it inflicts, but burdens

staff with complex issues and the healthcare

industry with increased costs and services. Al-

though exogenous sources of infectious mi-

croorganisms exist, it is typically the patient’s

own colonizing flora that is implicated in infec-

tion. The primary risk factor for the develop-

ment of hospital-associated bacterial

pneumonia is mechanical ventilation.

St. Catherine’s recognized the need to ad-

dress its rate of VAP in the critical care and

step down units. However, the facility lacked a

coordination of services. Each service was ini-

tiating its own treatment protocols and in

some instances either overlapping services or

not addressing issues at all. The hospital rec-

ognized the need to form a highly-motivated

team to tackle this problem and acknowl-

edged the need to address current practice

and improve patient safety. An extensive liter-

ature search led the hospital to look at its

basic practices for infection prevention. A risk

assessment was performed evaluating hand

hygiene compliance, sedation interruption, as-

sessment of readiness to wean, maintenance

of a semi-recumbent positioning, and oral

care. This gave St. Catherine’s a baseline to

determine where deficiencies existed. Educa-

tion was performed which included physicians,

nursing, respiratory therapy, radiology and

transporters.

Everyone was educated on all aspects of the

ventilated patient—especially the use of the

bundle and its role of “all or nothing” in the

prevention of VAP. On the Step Down Unit, the

hospital had chronic patients who were non-

weanable and usually not sedated, but all

other items in the bundle were carried out on

that unit.

Daily interdisciplinary rounds that discussed

aspects of best care such as head-of-bed ele-

vation, sedation vacation and oral hygiene

were performed. The hospital staff embraced

all best practices and made a determination

that oral hygiene was the most important as-

pect. Data on compliance to the process and

outcomes were presented to each department

via the Special Care and Infection Prevention

Committees. These data were also presented

to the Hospital Performance Improvement

Committee. Data were also shared with a col-

laborative. St. Catherine’s showed a marked

decrease in VAP with the use of oral hygiene

kits compared to other like facilities.

Since January 2008, VAP has been eliminated

on the Respiratory Step Down Unit and there

has been a sustained decrease in the inci-

dence of VAP in critical care in 2008 and 2009.


St. Charles Hospital

Improving Interdisciplinary Reporting of Pre-empted Medication Errors

Medication error reporting at St. CharlesHospital is an interdisciplinary process. Be-ginning in 2004-2005, team membersbegan to explore ways to recognize and im-prove the reporting of pre-empted errors.

While traditional reporting via the formal oc-currence reporting system was encouraged,other venues for the recognition and report-ing of medication errors were considered.The team determined that certain cate-gories in the clinical interventions per-formed by pharmacy and the MedicationAdministration Record (MAR) communica-tions generated by nursing could appropri-ately be recognized as pre-emptedmedication errors.

Beginning in 2004, St. Charles Hospital im-plemented the facility-wide utilization of anelectronic MAR. This changed the way med-ications were transcribed to the medicationrecord. When utilizing a traditional paperbased-medication record, the nurse had theprimary responsibility to transcribe the pa-tient’s medication orders to the record. Theconversion to an electronic record generateddaily, in conjunction with the utilization ofthe hard stop, placed the emphasis for tran-scription on the pharmacist. The nurse wasnow required to review the printed MAR fortranscription omissions or discrepancies.

Additionally, the department of pharmacybegan to develop and improve the trackingof completed clinical interventions. Clinicalinterventions may be defined as actions/in-terventions between the pharmacist and theordering clinician to either clarify, correct ordiscontinue a current order to the medica-tion profile. Intervention occurs prior to dis-pensing and administration of medications/treatments ordered.

The workflow processes for both nursingand pharmacy were simplified. The MARCommunication changes included addingcategories for incorrect or missing allergy in-formation and having the order number at-tributed to the profile entry printed on theMAR. This allowed the pharmacy to accessthe specific order in question immediately.Finally, clinical Intervention data capturewas improved by refining the interventioncategories and the development of an elec-tronic data base.


St. Charles Hospital

PUPs (Pressure Ulcer Prevention) Program

St. Charles Hospital has participated inyearly point prevalence surveys regardingpressure ulcers, and the results have beenused as benchmarks for improvement. Thepoint prevalence incidence rate for 2005was 15 percent. Through the PUPs pro-gram, the point prevalence incidence ratewas reduced to 3.3 percent in 2009.

The objectives of the PUPs program includeimproved identification of patients at risk forskin breakdown on admission; implementa-tion of interventions for prevention of pres-sure ulcers; and reduction in the rate offacility-acquired pressure ulcers.

Commonly, pressure ulcers are associatedwith individuals experiencing decreased ac-tivity/mobility, incontinence, poor nutrition,and advanced age. However, pressure ul-cers can also occur because of devicessuch as oxygen tubing, braces, splints, andin individuals where the burden of diseaseoverwhelms the skin resulting in skin(organ) failure. Challenges at St. Charles in-cluded changing the survey process from achart-based process to one of engagingstaff in physical assessment and chart re-view, standardizing and disseminating staff(nursing and physician) education, formingrevisions, implementing a process for riskassessments, enhancing communication

across disciplines and services, and facili-tating access to resources.

In addition to reducing the incidence ofpressure ulcers by more than 10 percent,the PUPs program achieved other measura-ble results. These include increased avail-ability and accessibility to resources forprevention; increased frequency of risk as-sessments and implementation of interven-tions; standardized education andincorporation of pressure ulcer preventiontopics to annual nursing skills fair; and de-velopment and revision of forms to facilitateimplementation and documentation of pre-vention measures and treatment, includingpre-printed physician orders.


St. Francis Hospital

Feet First: Enhancing a Culture of Safety to Achieve a Reduction in Patient Falls

Although St. Francis Hospital’s patient caredivision’s fall rate is consistently below thenational benchmark of 3.5 per 1000 patientdays, the hospital constantly strives to im-prove. The population the hospital servesconsists of many elderly patients who oftenexhibit polypharmacy, including the use ofanticoagulants, which could potentiate anyinjury sustained during a fall. The innova-tive process developed to further enhancethe falls reduction program incorporated amulti-faceted approach.

The program includes the use of a new fallsrisk assessment tool, which is completedevery 12 hrs. This tool enables the clinicalnurse to score patients on their gait, mentalstatus, falls history, use of narcotics/seda-tives, hemodynamic status and other fac-tors. A score of less than 18 indicates thepatient is at high risk for a fall. The empha-sis of the fall prevention program is imple-menting the appropriate intervention. FEETis the acronym used for the plan of care.The fall prevention plan of care lists nursinginterventions categorized as Functional,Equipment, Education, and Toileting.

Upon admission, all patients and familiespartner with the staff and receive a fallscontract. The contract remains posted onthe patient’s bulletin board for the duration

of hospitalization. In the event of a patientfall, an interdisciplinary team meeting oc-curs to analyze contributing factors and todevelop an action plan to prevent furtheroccurrences. Lessons learned from thismeeting are shared with all at the unit anddepartmental level.

The program achieved these outcomes. In2008 rate of falls was 1.2 per 1000 patientdays. In 2009, the rate of falls was 1.0 per1000 patient days.



Optimizing a Culture of Interdisciplinary Collaboration to Prevent Central Line-associatedBlood Stream Infections (CLABs) in Critical Care

The Institute for Health Improvement’s (IHI)Five Million Lives Campaign, along with theNational Health Care Safety Network, pro-vided the stimulus for a program needs as-sessment on the prevention of CentralLine-Associated Blood Stream Infections(CLABs) in the critical care units at St. Fran-cis Hospital. A review of the literature, data,advisory groups and existing expertise pro-vided the foundational grounding to allstakeholders. Increased scientific knowl-edge and understanding of these underpin-nings, allowed the hospital to develop aconceptual framework. Barriers were identi-fied and effective interventions were ap-plied to improve patient-specific,provider-specific, and payer-specific out-comes. Monthly performance improvementteam meetings, mini-root cause analysesand implementation of interdisciplinarydaily line stickers resulted in a 67 percentdecrease in CLABs rates.

The program incorporated the followingchange principles: purchasing, stocking andreplacement patterns for unit line carts;monitoring of barrier precautions and steriletechniques at times of line insertion with thenurse empowered to stop a procedure dueto lack of adherence; credentialing of mid-level practitioners to insert peripherally-in-serted central catheter lines; the utilization

of IHI CLABs bundle and interdisciplinary redsticker for the necessity of lines and mainte-nance documented daily; the utilization ofchlorhexidine and alcohol swabs with 10twists prior to accessing each port; the im-plementation of daily chlorhexidine baths forall patients with central lines for more thanfive days; utilization of monofilament su-tures, rather than braided silk, when indi-cated; appropriate placement of monitorlead; and the creation of a positive environ-ment with signage for public and staffdemonstrating the number of days withoutCLABs.

Results were remarkable. Quarterly rates in2009 demonstrated a positive trend from1.4 to 0.6 CLABS in ICU patients per 1,000line days; the baseline of 2008 was 3/1000line days and the target was 1.8/1000 linedays. The hospital was able to achieve re-sults below the baseline and the target for arate of 1/1000 line days. Beginning in Juneof 2009, one of the ICUs achieved zeroCLABs for seven consecutive months andzero CLABs were obtained in all critical careunits for four months in 2009.



Skin Integrity: Nursing Interventions and Clinical Nurse SKIN Champions

The prevalence of hospital-acquired pres-sure ulcers is a national issue. There areproven interventions that are beneficial tothe maintenance of skin integrity.

The premise of the Skin Care Bundle (SCB)is to incorporate the necessary steps innursing practice and to prioritize thesesteps utilizing the power of redundancy.The implementation of the SCB promotedteamwork, as supportive personnel assistprofessional nurses with turning, positioningand basic comfort care measures. The SkinCare Bundle was initiated in critical careunits as an original research project. Theexperience of the critical care unit nurses inpressure ulcer prevention and in providingcare to a high- risk population ensured thehigh-reliability of the SCB. The bundling ofthe SCB components provided continuousavailability of evidence-based practice, aswell as a high level of insurance in maintain-ing the all or nothing approach of the SCB.This maximized pressure ulcer prevention inthe critical care unit.

The SCB was implemented hospital-wide inthe fourth quarter of 2008. In addition tothe SCB, the SKIN Champions initiative wasimplemented, involving a three-month com-mitment from staff nurses on each patientcare unit as SKIN Champions. The nurses

committed to participate in educational sem-inars and to support their peers and modelbest practice in pressure ulcer prevention.In combination, these two innovative initia-tives have dramatically reduced the inci-dence of hospital-acquired pressure ulcers.

In 2008, the overall rate of hospital-acquired pressure ulcers was 5.47. In2009, the overall rate of hospital-acquiredpressure ulcers was 2.4. This is a decreaseof 56 percent from 2008 to 2009.


South Nassau Communities Hospital

Maintaining the Momentum on Patient Throughput

Challenges of patient flow or “throughput”brought about by increasing volume in theEmergency Department and PerioperativeServices presented mirror images ofbroader patient care access issues re-flected through these two service lines. Toimprove performance, the hospital analyzedcollaborative interdepartmental processesregarding patient admission, staffing, regis-tration, bed turnaround time, patient dis-charge, transport and placement.

Operational and systems-based initiativeswere designed to increase the efficiencyand timeliness of key processes related topatient throughput. These included en-hancement of a Bed Demand EscalationPlan; establishment of a designated BedCoordinator and an Assistant Director ofNursing with oversight for Patient Through-put; continuation of an ongoing Care Man-agement Length of Stay project; conveningof daily tactical bed board care coordinationteam meetings for the identification of pa-tient placement needs and discharge barri-ers; devising specific cardiac monitoringadmission criteria resulting in increasedavailability of cardiac monitors; direction ofhospitalist admissions for co-horting of pa-tients on a dedicated unit; installation of anEmergency Department Patient TrackingDashboard promoting quick view status of

patient diagnostics, disposition and coremeasures indicators; implementation ofbedside patient registration in EmergencyDepartment; execution of bedside handoffof care reports in the Emergency Depart-ment by critical care nurses; and launch ofan innovative, flexible staffing solution con-necting an untapped supply of nurses withthe demand of registered nurse staffingneeds using a non-traditional schedulingprocess.

One significant outcome included a 27 per-cent increase in favorable responses asmeasured by the Hospital Consumer Assessment of Healthcare Providers andSystems category, “Time Spent in the Emer-gency Department.” Other positive resultsincluded a 30 percent decrease in timefrom the Emergency Department to criticalcare patient transfers over a three-monthperiod, a 24 percent decrease in “time ofadmit to arrival on unit” over a six-monthperiod, and a 28 percent decrease in “Red”(total bed capacity) hours in 2009.


South Nassau Communities Hospital

Re-designing Processes to Prevent Hospital-acquired Venous Thromboembolism (VTE)

Our institutional incidence of VTE, as well ascompliance with existing protocols, was re-viewed. Standardizing protocol, simplifyingthe protocol order set, designing the orderset’s integration into the clinician workflowand presentation of mandatory physicianeducation regarding the problems associ-ated with hospital-acquired VTE were all keyto the project’s success. Data were col-lected during all of 2008 and 2009. Theproject began during 2008 and new proto-cols were fully implemented by July 2009.

Two multidisciplinary teams (medical andsurgical) were charged with evaluating thecurrent processes for VTE prophylaxis. Eachteam was led by a physician team leaderwho had expertise in VTE prevention andprophylaxis. The teams utilized a modified“failure mode and effects analysis” ap-proach to identify the possible reasons thatthe current VTE prophylaxis may be under-utilized. Once the major issues were identi-fied the team employed the “plan, design,measure, assess, improve” approachmethodology for the project. Baseline datawere reviewed and the team developedmeasurable goals and metrics with accom-panying timeframe of 12 to 18 months forproject completion. Performance improve-ment staff reviewed all open available med-ical records during one week in each

quarter to assess for the appropriateness ofrisk identification and appropriate prophy-laxis (approximately 250-300 records perquarter). Exclusion criteria included obstet-rical, psychiatric, and pediatric patients.

Prior to implementation, the facility’s rateof hospital-acquired VTE was 0.43 for 1,000patient days. A rate of 0.35 for 1,000 pa-tient days was achieved in the first sixmonths after implementation. The percent-age of appropriate prophylaxis was initially66 percent, but increased to 86 percent forthe six months following implementation.


Southampton Hospital

A Nursing Strategic Plan Built Upon a Foundation of Patient Safety

In 2006, the department of nursing con-ducted a needs assessment focusing onquality/patient outcomes, recruitment/re-tention, and patient safety. Part of the as-sessment included distribution of theAssociation for Healthcare Research andQuality (AHRQ) Hospital Safety Survey to thedepartment staff. Respondents rated thecategories of overall perception of safety at33 percent, communication openness at 49percent, and patient handoff at 28 percent.Further, the department of nursing identi-fied dedicated staff in areas not supportedby systems and processes conducive to pro-moting patient safety,

Southampton Hospital’s goal was to createa nursing strategic plan with a visible com-mitment of leadership, raise awareness ofpatients at risk for harm, and foster an envi-ronment of safe practice. This was accom-plished through the promotion oftransparency, insight gained by conductingroot cause analysis, real-time coaching andguidance to the staff, re-introduction of thenursing code of ethics, transitioning nursingshift-to-shift report from the conferenceroom to the bedside, which includes the pa-tient in the daily plan of care, clinical/ad-ministrative staff rounding, and otherinternal changes.

The project utilized the principles of continu-ous quality improvement: involvement ofstaff at all levels; utilization of standardizedaccepted tools as a means of measure-ment; establishment of a baseline to meas-ure results; benchmarking both internallyand externally; and utilizing best practicestandards to promote change.

The Hospital Safety Survey was re-distrib-uted in 2009 and improvement was foundin all areas. The overall perception of safetyincreased 40 percent, open communicationincreased 24 percent, handoffs increasedby 32 percent, and the registered nurse va-cancy rate decreased, as did the averagemonthly turnover rate.



Southside Hospital

Improving Pain Management in the Limited English Proficient (LEP) Population

Pain management should be accessible toall patients, regardless of race, class, gen-der or language. In diverse communities,language and culture may play a significantrole in how staff regards the pain of others.The goal of this initiative was to improvepain management for LEP patients by in-creasing staff and physician awareness tocultural differences in the patient popula-tion utilizing a multi-factorial approach.

In 2004, the Nursing Performance Improve-ment Department began analyzing perform-ance data on pain management for LEPpatients. At that time, nurse managerswere performing chart reviews to discernhow well pain was managed for all patientswith regard to delivery, scoring, assessmentand re-assessment of pain. Initial analysison Press Ganey scores suggested that therewas a strong negative relationship betweennursing staff’s subjective scores on howwell they were managing pain and patients’subjective scores on how well they believedtheir pain had been managed during theirhospitalization.

Consequently, interviews with staff aboutpain management suggested that therewere often language barriers that preventedthem from doing a better job for LEP pa-tients. As a result, three initiatives were

implemented in the peri-natal areas: (1)better use of interpreter services in the peri-natal areas, (2) physicians’ orders to eitherorder patient-controlled analgesia (PCA) orround the clock (RTC) administration ofanalgesia and (3) the provision of educationand consciousness-raising for nursing staffand physicians with regard to pain manage-ment in a diverse community.

As a result of these efforts, pain manage-ment scores for both English-speaking andLEP patients have risen significantly be-tween January 2005, when earnest effortsbegan to improve pain management for LEPpatients, and December 2008, the last pe-riod studied. Pain management and re-spect for cultural needs were highlycorrelated. Significant improvements in thepost-partum area on pain managementwere found in the general patient popula-tion for the same period (2005-2008). Fur-thermore, significant culture and paincorrelations were found in both the Englishspeaking and non-English speaking patientpopulations.


Stony Brook University Medical Center

Fostering Organization-wide Use of Failure Mode and Effect Analyses (FMEA)

Utilizing Failure Mode and Effect Analyses(FMEAs) allows for the ability to proactivelystudy high-risk processes, identify potentialfailure modes in these processes, and as-sess the severity, frequency and detectionof failure modes using standardized scales.By calculating a risk priority number (RPN),a team may identify significant risk pointsrequiring the implementation of risk reduc-tion strategies to improve performance andsafety. To ensure success, these interven-tions are measureable and focus on sys-tematic process deployment.

Most notably, although the Joint Commissionon Accreditation of Healthcare Organizationsrequires accredited healthcare organizationsto conduct one proactive risk assessmentper year, Stony Brook University Medical Center, continually embedding a culture ofpatient safety, requires every department toconduct a FMEA throughout the year, on acontinuous basis. Each department is re-quired to conduct an FMEA within threemonths and, after completion, is required toidentify the next FMEA for implementation.Organizationally, the goal is to implementnearly 100 FMEAs annually. Every leader,department head, and nurse manager wereprovided training and tools to allow them tofacilitate FMEAs with interdisciplinary teamsusing standardized tools. They are required

to select high-risk processes and apply theuse of the FMEA methodology to identifyand implement risk reduction strategiesand measure the effectiveness of interven-tions. By continually implementing multiple,simultaneous FMEAs, it will allow the organi-zation to hasten the goal to systematicallydeploy key processes and reduce error,while improving safety.

Outcomes were significant. They included adecreased ratio of falls to falls-with-injuryfrom 34 percent to 15 percent; improvedEmployee Annual Physical Assessment ratesfrom 74 percent to 97 percent compliance;an increased number of quarterly safety in-cident reports generated by the bedsidenurse from 10 to 25 on a unit; and im-proved endotracheal intubation by para-medics relating to medication and dosingfrom 82 percent to 100 percent.



Stony Brook University Medical Center

Standardization to Prevent Venous Thromboembolism (VTE)

Stony Brook University Medical Center identi-fied an opportunity to improve standardizingDeep Vein Thrombosis (DVT) risk assessmentand orders for prophylaxis to improve patientsafety. In order to standardize assessmentsrelating to DVT prophylaxis, an electronic solu-tion was established to systematically deployan improved process which utilizes the Na-tional Quality Forum (NQF) recommendations;Joint Commission Standards and the Ameri-can College of Chest Physician (ACCP) estab-lished guidelines. As a result of implementingan electronic solution, adult patients hospital-wide (excluding psychiatry) are assessedwithin 24 hours of admission and appropriateorders are established.

Establishing the need and subsequent execu-tion of a VTE prevention solution occurredthrough the formation of a key stakeholdergroup with strong stakeholder presence.Hospital data reviewed suggested that therewas an opportunity to improve assessing pa-tient risk of acquiring a VTE. All medical andsurgical services (including pediatrics andpsychiatry) were asked to review currentguidelines and identify care practices withintheir specialties that were not addressed inthe national guidelines. The review and sub-sequent input from physicians was discussedand “buy in” from all areas regarding carepractice was established. A policy and proce-dure to systematically standardize processesrelating to DVT prophylaxis was also created.Key hospital leadership was provided thedata and methodology of the team’s improve-ment strategy.

The electronic solution provides standardizedaccess to the electronic assessment, physi-cian orders, and key safety clinical considera-tions. An innovative, breakthrough strategy toensure high reliability is the hard wiring ofcompliance through the electronic patientrecord. The patient ordering function is“locked” if an assessment is not completedwithin 24 hours of admission. To unlock therecord the Licensed Independent Practitioner(LIP) must complete the assessment and re-view and select the recommended orderswhen indicated. Two additional aspects ofthe electronic solution individually standalone as a breakthrough strategy in healthcare. A “real time” electronic alert is gener-ated when specific labs abruptly change, indi-cating a patient is at risk with therapy. Thesecond solution is the electronic “lab moni-tor” that provides alerts and orders tests au-tomatically 18 hours after the first dose ofpharmacologic regimen is received. In addi-tion, LIPs now have a direct electronic link toresources when additional clinical considera-tion is necessary.

Overall, since the initiation of the electronicsolution, VTE events decreased from a rate of0.49 per 1000 days during a seven-month pe-riod. Prior to the plan’s implementation, theassessment within 24 hours was 64 percent.Post implementation of the electronic solu-tion in November 2009, that assessmentrose to 91.2 percent.




Code H Obstetrical Hemorrhage, Development of a Team Approach

In 2004, the New York State Department ofHealth (NYSDOH) issued a health advisorystating that maternal mortality rates in NewYork State are higher than the national aver-age, and hemorrhage is the leading causeof mortality. It further asserted that healthcare providers can prevent maternal deathsby improving recognition and response tohemorrhage; blood loss is frequently under-estimated; the causes of death due to hem-orrhage are multi-factorial; and preventionrequires a multidisciplinary response. Itadvised that hospital systems with a rapidand coordinated response to extreme bloodloss can limit maternal morbidity and im-prove maternal survival.

When this same advisory was reissued in2009, a task force was convened to furtherdevelop an interdisciplinary team responseto hemorrhage and look at system factorsthat result in delays in recognition andtreatment.

Some improvement strategies included es-tablishing a multidisciplinary obstetricalhemorrhage team consisting of an obstetricanesthesiologist, chief resident, attendingphysician, labor and delivery nurse andblood bank supervisor. The program alsoincluded massive staff education on estima-tion of blood loss and recognition and

response to hemorrhage. A massive trans-fusion protocol was established. Release ofblood products and lab results facilitatedthe creation of a code H cart containingemergency equipment and a referencemanual with emergency phone numbers, di-agrams of emergency maneuvers, and med-ication information.

As a result of this team approach, the staffnow recognizes and responds to significantblood loss sooner. The approach also fos-ters better defined roles, communication,and patient-focused nursing care. In addi-tion, a massive transfusion protocol was es-tablished and implemented the response ofblood bank to blood product requests be-came more timely and efficient. Now,nurses feel supported because they can ac-tivate Code H. Hemorrhages are reviewedwith specified data criteria and process im-provement follow-up occurs.



Got Milk? Vital: Human Milk for premature infants

The New York State pre-term birth rate is12.4 percent, and Nassau County has oneof the highest rates in New York State (Peri-stats, 2009). Pre-term infants are at con-siderable risk for increased morbidity andmortality compared to their full-term coun-terparts. They have a higher risk of learningdisabilities, cerebral palsy, sensory deficits,respiratory illnesses and gastrointestinal ill-nesses than full-term infants, according tothe March of Dimes.

Mothers’ Own Milk (MOM) has been demon-strated to have multiple benefits for pre-term infants. Providing MOM to thepre-term infant has nutritional, gastrointesti-nal, immunological, developmental and psy-chological benefits, according to popularclinical literature and studies in this area.In addition, breast-fed pre-term infants havea lower rate of ear infections, respiratory in-fections, or infection-related events. Theyalso have lower rates of gastrointestinal in-fections, specifically necrotizing enterocoli-tis and lower mortality rates. Breast-fedpre-term infants are discharged earlier fromthe Neonatal Intensive Care Unit (NICU)than their formula-fed counterparts.

In this vulnerable population, the rates ofmothers providing MOM are decreasedwhen compared to their healthy newborn

counterparts. Increasing the amount ofMOM, and providing donor milk in the NICUwas the goal of this project. This wasachieved by dedicating a NICU lactationconsultant; nursing and resident education;symphony premie pumps; rental pumps withinsurance reimbursement; and donor milk.

Outcomes achieved with this program in-cluded an increased percentage of mothersproviding MOM from 73 percent to 93 per-cent; increased MOM production utilizingthe symphony premie pump; increased in-surance reimbursement for breast pumprentals and decreasing the cost; providinghospital-grade rental pumps to go homewith mothers; a tissue license to distributedonor milk; and nursing and resident awareness/education.



CPOE System Enhanced by Visual Cues

Clinical information systems improve manyof the safety challenges identified within thepaper process. This technology also createsnew challenges and patient safety concerns.

The hospital implemented a computerizedphysician order entry (CPOE) in July 2006.During system development, a risk pointwas revealed relative to compliance with thehospital’s patient identification policy. Thesystem did not have a patient verificationprocess built into the ordering pathway. Inresponse, Winthrop customized the systemby adding a patient verification screen thatincluded the patient identifiers that weredefined in the hospital’s policy and an ac-knowledgement button that the providerwould select to proceed.

Despite implementation, we saw a rise inwrong patient selection. Investigations re-vealed the ease with which a provider canunintentionally select the wrong patient dueto distraction, “point & click” or keystrokeerrors. The verification screen was notenough; providers became “immune” to thescreen and went to the “OK” button and didnot take the time to verify the information.

Development of a verification screen thatmandated an active process from theprovider was created using visual cues (i.e.

colors) and active entry of information. Thisforced the provider to pause and think be-fore proceeding. The active input portion ofthe screen is moved to different areas ap-proximately every three months to promotevisual stimulation and prevent task-orientedbehavior.

The results of this change were dramatic. In2009, 37 instances of wrong patient selec-tion were received via the electronic report-ing system and verbal quality improvementreports. All selections reported involvedwrong order entry of blood products or med-ication. However, none reached the patient.CPOE increased awareness and trans-parency of errors. After implementation ofthe new patient verification screen, one inci-dent of wrong patient selection due to userdistraction has been reported.


NASSAU-SUFFOLK HOSPITAL COUNCIL

Representing the not-for-profit and public hospitals serving the residents of Long Island

1383 Veterans Memorial Highway, Suite 26Hauppauge, New York 11788

Phone (631) 435-3000 ~ Fax: (631) 435-2343

www.nshc.org

Doug Melzer, Chairman of the BoardKevin W. Dahill, President/CEO

Wendy D. Darwell, Vice President/COO

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